Sign Up for Your Next Massage Therapy Appointment

Name:

Phone:

Email:

Address:

City/State/Zip:

Date of Birth

Occupation:

Emergency Contact:

Contact Phone:

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The following information will be used to help plan safe and effective massage sessions. Please answer the questions to the best of your knowledge. *Hours are by appointment only.*

Have you had a professional massage before?

Yes

No

If yes, how often do you receive massage therapy?

Do you have any difficulty lying on your front, back, or side?

Yes

No

If yes, please describe:

Do you have sensitive skin?

Are you wearing contact lenses, dentures, or a hearing aid? Check all that apply.

Contact Lenses

Dentures

Hearing Aid

Do you sit for long hours at a workstation, computer or driving?

If yes, please describe.

Do you perform any repetitive movement in your work, sports, or hobby?

If yes, please describe.

Do you experience stress in your work, family, or other aspect of your life?

If yes, how do you think it has affected your health? Select all that apply.

Muscle Tension

Anxiety

Insomnia

Irritability

Allergies/Sensitivities

Is there a particular area of the body where you are experiencing tension, stiffness, pain, or other discomfort?

If yes, please identify.

Do you have any particular goals in mind for this session? If yes, please describe.

Are there any specific areas that you would like us to pay special mind to during your session? If yes, please describe.

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Medical History • In order to plan a massage session that is safe and effective, I need some general information about your medical history.

Are you currently under medical supervision?

If yes, please explain.

Do you see a chiropractor?

If yes, how often?

Are you currently taking any medications?

If yes, please list.

Please check any conditions below that apply to you (1/2):

Please check any conditions below that apply to you (2/2):

If pregnant, how many months?

Please explain any condition that you have above:

Is there anything else about your health history that you think would be useful for your massage practitioner to know to plan a safe and effective massage session for you?

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Draping will be used during the session. Only the area being worked on will be uncovered. Clients under the age of 17 must be accompanied by a parent or legal guardian during the entire session, and informed written consent must be provided by a parent or legal guardian for the client.

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I understand that the message I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort.

I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment that I am aware of.

I understand that message therapists are not qualified to perform spinal or skeletal adjustments, to diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such.

Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly.

I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist's part should I fail to do so.

Check "I understand" to formally imply your compliance with the above statement:

I understand

Enter your name as a formal signature:

Enter date signed:

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Massage Therapy Intake Form

Intake Form - Massage Therapy