Massage Intake Form

Full Name

Date of Birth (MM/DD/YY)

Gender

Address

Address Line 2

Preferred Phone Number

Emergency Contact Person

Emergency Contact's Phone

Is this massage/bodywork medically necessary (is it for a medical condition, injury, surgery)?

Do you have a physician referral/prescription?

Yes

Have you ever received professional massage/bodywork before?

Yes

What types of massage/bodywork do you prefer?

What kind of pressure do you prefer?

Light

Medium

Firm

What are your goals/expected outcomes for receiving massage/bodywork?

List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):

Do these symptoms interfere with your activities of daily living (e.g., sleep, exercise, work, childcare)?

List the medications you currently take:

Are wearing contacts?

Yes

Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received:

CONSENT FOR TREATMENT: If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage/bodywork 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 of which I am aware. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, 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/bodywork 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 practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. Understanding all of this, I give my consent to receive care.

Please re-type your full name here

Today's Date (MM/DD/YYYY)

Thank you for booking a Massage Session!

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