Fillable Massage Wellness Chart With Patient Intake Form printable pdf download

Massage Wellness Chart

Name ___________________________________________________________________________________________________________________

Address ______________________________________________________ City __________________________ State ______ Zip ______________

Please help us ensure a safe and comfortable massage experience by providing the following information. Check all that apply and explain.

Health history:

Allergies (nuts, shellfish, scents, etc): ________________________________________________________________________

Arthritis: _______________________________________________________________________________________________

Blood clots: _____________________________________________________________________________________________

Blood pressure conditions: ________________________________________________________________________________

Chronic pain (joint, muscle, nerve): __________________________________________________________________________

Diabetes: _______________________________________________________________________________________________

Fibromyalgia: ___________________________________________________________________________________________

Headaches:_____________________________________________________________________________________________

Heat sensitivity: _________________________________________________________________________________________

Heart problems: _________________________________________________________________________________________

History of strokes: _______________________________________________________________________________________

Infections: ______________________________________________________________________________________________

Injuries: ________________________________________________________________________________________________

Insomnia: ______________________________________________________________________________________________

Immune system deficiencies: _______________________________________________________________________________

Lupus: _________________________________________________________________________________________________

Medications: ____________________________________________________________________________________________

Pain, numbness, tingling: __________________________________________________________________________________

Skin conditions (bruising, acne, rash): ________________________________________________________________________

Surgeries: ______________________________________________________________________________________________

Varicose veins: __________________________________________________________________________________________

Other: _________________________________________________________________________________________________

Pregnancy: _____________________________________________________________________________________________

Daily activities affected by stress/pain/condition: __________________________________________________________________

Desired massage pressure: ___ LIGHT ___ MEDIUM ___ DEEP

Are you under the age of 18? ___ YES

___ NO

If yes, written parental permission is required.

Areas of stress or pain:

(0 = No pain, 10 = High Pain)

Neck _____

Back _____

Legs _____

Shoulders _____

Arms _____

Other: ________________________

Welcome to 22 Health Group, LLC (referred to herein as “we” or “us”). We require our therapists to adhere to a Code of Conduct intended to provide a safe, professional, and therapeutic environment

for our guests. If you have any concerns about you therapist, please bring it to the attention of management immediately. Male/female genitalia and women’s breasts will not be exposed or massaged

at any time. Modest draping will be used during the session. If at any time during the session you feel uncomfortable, simply ask your therapist to end the session. It is your responsibility to inform us of

any pre-existing conditions, limitations, or specific sensitivities and to inform your therapist if you feel any discomfort during your session. If you experience discomfort, you may ask the therapist to

adjust the pressure or heat, or you may ask to end the session, depending on your level of discomfort. You understand, acknowledge, and voluntarily accept the risk associated with massage services

and use of our facilities, and you hereby release us from liability for any injury or claim (including, without limitation, personal, bodily, or mental injury, property damage or economic loss), which may

result from your massage(s); your failure to disclose any pre-existing condition, limitation or sensitivity; or your failure to inform your therapist of discomfort during your session. We may, in our sole

discretion, refuse or discontinue massage services if we determine such services may be unsafe or cause discomfort for you. The undersigned acknowledges he/she has read and understands this

disclaimer. Cancellations: All appointments must be cancelled no later than 24 hours prior to your appointment. If a cancellation is made less than 24 hours from your scheduled appointment, a $20

cancellation fee will be applied to your account. You will no longer be able to receive massages unless the balance has been paid in full.

Signature _________________________________________________________ Date _________________________________