Massage Intake Form

Massage will not be performed if you arrive intoxicated, under the influence of drugs, needing to bathe or unreasonably late. In accordance with state laws, your body will be properly draped (covered) at all times, except for the area being worked.

Contact Information

Name ________________________________________ Nickname: ___________________ Birthdate ___________________

Address ______________________________________ City ______________________ State ______ Zip Code ___________

Occupation ______________________________ Day phone __________________ Evening phone ___________________

E-mail: _________________________________________Have you ever had a professional massage? Yes ____ No ____

What do you hope to gain from massage therapy? ______________________________________________________________

Current Medical Information

Are you currently under medical care? Yes ___ No ___ If yes, please explain ______________________________________

Are you receiving professional counseling? Yes ____ No ___ If yes, please explain _________________________________

Is there ANY chance you are pregnant or trying to conceive? Yes ___ No ___ If pregnant, number of weeks __________

Please list all medications/vitamins/herbal supplements you are currently taking _______________________________________

_______________________________________________________________________________________________________

Do you wear contacts? Yes_____ No_____ Dentures? Yes_____ No_____ Hearing aid? Yes_____ No_____

Medical History

All of this information is confidential, and cannot be shared with anyone by law. Please include any recent rashes, bruises, bumps, breaks, sprains, strains, fractures, illnesses, or surgeries. A partial list follows but is not meant to be all-inclusive.

___ Abscess/open sore/surgical site	___ Fibromyalgia	___ Implants
___ Allergies	___ Fibrositis	Where __________________
___ Arteriosclerosis	___ Headaches	___ Lupus
___ Asthma	___ Heart disease	___ PMS/troublesome cycle
___ Cancer/undiagnosed lump	___ Herniated/ruptured disc	___ Pregnancy (currently)
Type ___________________	___ Hepatitis	___ Osteoarthritis
Diagnosed date ___________	___ Herpes I or II	___ Osteoporosis
Last treatment ____________	___ History of mental illness,	___ Phlebitis
___ Chronic fatigue syndrome	Physical or emotional abuse,	___ Rheumatoid Arthritis
___ Depression	Counseling/therapy	___ Skin sensitivity
___ Diabetes	___ HIV/AIDS	___ Stomach ulcers
___ Digestive problems	Diagnosed date ___________	___ Varicose veins
___ Easy bruising	Last treatment ____________	___ Other conditions (include past
___ Epilepsy	___ Hypertension	injuries) that still affect you:
___ Fluid retention	___ Inner ear problems	_____________________________
___ Fractures/breaks/sprains	___ Insomnia	_____________________________
Physician Information (This section MUST be completed if you have conditions such as Diabetes, High Blood Pressure, Lupus, Cancer, HIV/AIDS, etc.)
Physician’s Name ___________________ Phone ___________________ City ________________ State _____ Zip ______
Do we have your permission to contact your healthcare provider if needed? Yes _______ No _______
Lifestyle/Fitness Routine
How often do you exercise weekly? _____________ What type(s)? ____________________________________________
Do you use tobacco? Yes _____ No _____ Alcohol? Yes _____ No _____ Caffeine? Yes _____ No _____
How many glasses of water do you consume daily? ______ On a scale of 1 to 10, what is your stress level? _____
What type of massage pressure do you prefer? Featherlight ____, Gentle ____, Moderate ____, or Deep/Heavy ____
Is there any area of the body where you seem to hold a lot of tension? _______________________________________
I have read the preceding information and understand it is my responsibility to inform the therapist of any of my health challenges and issues prior to EACH session. I understand that any medical condition/illness/injury that I currently have MUST be documented on this form, and the therapist cannot be held liable for any adverse reactions related to any conditions that have been concealed by me. I understand that this work does not constitute medical treatment. It is a form of health maintenance and wellness, utilizing the techniques of traditional massage.
Client Signature ________________________________________ Date _________________ Referred by _____________________________________________________________________