Intake Form

Name

Address

Home Phone

Email

Occupation

Emergency Contact

Phone


Your Session

What are you looking primarily for in your massage today?
Full Body ExperiencePrecise Therapeutic AttentionBoth

Please use the diagram below to indicate areas of tension of discomfort.


ABCDEFGHIJKLMNOP
Muscle Diagram

I would like my massage to be more:

Smooth and Flowing .................................................Deep and Focussed

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My Tolerance for pressure is:

I am a delicate rose petal .........................................I don't feel pain

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Medical History


Do you exercise regularly?
YesNo


Type


Are you currently under the care of a physician?

YesNo


Name, Phone Number and what for?


Are you using any medication or other substances? If yes, please state below.


Please list any surgeries, accidents, or major illnesses.


Please review the following list and check those conditions that have affected your health either recently or in the past:


ArthritisAsthmaDiabetesBlood ClotsBack Problems/ScoliosisBroken/Dislocated bonesBruise EasilyCancerChemical DependencyChronic FatigueChronic PainConstipation/DiarrheaDepression,Panic Disorder, or other Psych Conditions


Any Communicable Diseases?


Consent for care

Please read the following and sign below.

1. I understand that although massage therapy can be very therapeutic, it is NOT a substitute for medical examination, diagnosis, and treatment.

2. I acknowledge that massage should not be done under certain medical conditions and I affirm that I have answered all questions pertaining to

medical conditions truthfully. I will inform my practitioner of any changes in my health status, and all-important communication from other care practitioners.
3. I understand that this is a therapeutic massage and any sexual remarks or advances will terminate the session, and I will be liable for payment of the scheduled treatment.

It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage.

Client Signature