~ Massage and Bodywork Intake Form ~

   
Client Information
 
Name:
Date:
Street:
Day Phone:
City/State/Zip:
Eve Phone:
Occupation:
Date of Birth:
Emergency Contact Name:
Emergency Phone:
Referred by:
Email:
 
Massage History / Session Information
Have you ever had a professional massage? Yes No
Date of last massage:
What results do you want from massage?
List exercise activities and Freqency
Are you currently under the care of a health care practitioner? Yes No
If yes, please specify purpose
List medication and purpose
Previous History (Include year and treatment received
Surgeries
Injuries/accidents/illnesses
Please mark any of the following that you now have or have had
Musculoskeletal
Circulatory
Bone or joint disease
Heart Condition
Tendonitis / Bursitis
Phlebitis / Varicose Veins
Arthritis / Gout
Blood Clots
Jaw Pain (TMJ)
High / Low Blood Pressure
Lupus
Lymphedema
Spinal Problems
Thrombosis / Embolism
Other
Other
Respiratory
Skin
Breathing difficulty / Asthma
Skin Allergies specify
Emphysema
Rashes
Respiratory Allergies specify
Athletes foot
Sinus problems
Herpes / Cold sores
Other
Other
Nervous System
Digestive
Shingles
Irritable Bowel Syndrome
Numbness / Tingling
Ulcers
Pinched Nerve
Other
Other
Reproductive
Other
Pregnant: Stage
Cancer / Tumors
Ovarian / Menstrual problems
Bladder / Kidney Aliment
Prostate
Diabetes
Other
Drug / Alcohol / Caffeine / Tobacco
Additional remarks/comments:
Chronic Fatigue
Chronic Pain
Sleep Disorders
Migraines / Headaches
Anxiety / Stress Syndrome
Depression
Contact Lenses
body

Areas of pain or discomfort

I have completed this form to the best of my knowledge and will inform the massage therapist of any change in my physical health.

I understand that a massage therapist can not diagnose illness, disease, or any other medical, physical, or emotional disorder, nor perform any spinal manipulations. I am responsible for consulting a qualified physician for any physical ailments that I have.

I understand that massage therapy is a therapeutic health aide and is non-sexual.

I understand that if the massage therapist starts a session late, she will make it up at the end of my session if possible, or will reduce my fee accordingly. I understand that if I arrive late, my session will end at the originally scheduled time so the client following me is not penalized.

I agree to give 24-hour notice for a scheduled session that I can not keep. I am aware that I may be charged 50% of fee for any missed sessions or for sessions that I do not give 24-hour notice to cancel or reschedule.

Signed:
Date:
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Me Too Massages
Loudon Drive | Fishkill, NY 12524
Phone: 845.549.4402 | Email: metoomassages@gmail.com

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