Therapeutic Massage Client Intake Form (Page 2 of 2) in pdf

Medical History

Do you currently or have you ever had any of the following: (please check)

phlebitis

tennis elbow

deep vein thrombosis/blood clots

recent fracture

joint disorder

recent surgery

rheumatoid arthritis/osteoarthritis/tendonitis

artificial joint

osteoporosis

sprains/strains

epilepsy

current fever

headaches/migraines

swollen glands

cancer

allergies/sensitivity

diabetes

heart condition

decreased sensation

high or low blood pressure

back/neck problems

circulatory disorder

Fibromyalgia

varicose veins

TMJ

atherosclerosis

carpal tunnel syndrome

easy bruising

contagious skin condition

recent accident or injury

open sores or wounds

pregnancy If yes, how many months?

Are you currently under medical supervision?

Yes

If yes, please explain_______________________________________________________________

Do you see a chiropractor? Yes No

If yes, how often?________________________________________

Are you currently taking any medication?

Yes

If yes, please list _________________________________________________________________

Is there anything else about your health history that you think would be useful for your massage therapist to

know to plan a safe and effective massage session for you? ____________________________________

_____________________________________________________________________________________

I understand that the massage I receive is provided for the basic purpose of relaxation and relief of

muscular tension. If I experience any pain or discomfort during my session, I will immediately inform the

therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand

that massage should not be construed as a substitute for medical examination, diagnosis, or treatment and

that I should see a physician other qualified medical specialist for any mental or physical ailment that I am

aware of. I understand that massage therapists are not qualified to perform 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 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 therapist updated as to any changes in my medical profile and understand that there shall be no

liability on the therapist’s part should I fail to do so.

Signature of client ______________________________________________ Date ___________________

Signature of Massage Therapist ___________________________________ Date ___________________

Therapeutic Massage Client Intake Form Page 2

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