One Woman Spa Massage Health Intake Form printable pdf download

One Woman Spa Massage Health Intake Form

Name:______________________________________________ DOB:_______________

Address:________________________________________________________________

City:__________________________________ State:____________ Zip:_____________

Best # to Reach you: (______)________________________________ ______________

E‐Mail:_________________________________________________________________

Physician Name/Phone:____________________________________________________

Emergency Contact:_______________________________________________________

What is your Occupation? ______________________________________

Have you had a professional massage before?

What would you rate your stress level as?

__Mild

__Moderate

__Severe

Are you on ANY medications or Supplements? (either topical or internal)

If so, Please list: _______________________________________________

Are you seeing a Physician for ANY reason?

If So, Please list: ______________________________________________

Do you have ANY allergies?

If so, Please List: ______________________________________________

Have you had ANY surgery in the last 6 months?

If so, Please list: _______________________________________________

Do you have high or low blood pressure? (please circle)

If so, what is your BP? _________________________________________

Do you have Diabetes? If so how is it controlled? _____________________

Do you have spinal problems?

Do you see a Chiropractor regularly

Do you have circulatory problems, spider veins, varicose veins, or blood clots?

In the last 6 months have you had an infectious or contagious disease?

Have you been experiencing prolonged periods of depression?

If so, what are you doing to help this? ______________________________

Do you wear contact lenses? Hard or soft? ___________________________

Do you wear a hearing aid?

Are you pregnant? If so what trimester? ____________________________

Do you have ANY other medical conditions that I should be aware of?

____________________________________________________________

Other than relaxation, what specific results would you like from today’s

massage?___________________________________________________

Disclaimer:

I the undersigned understand that all the information above is true to the best of my knowledge. I understand that my Massage

Practitioner does not diagnose illness, disease, or any other physical or mental disorder. I have told my Massage Practitioner all

the information needed to proceed with this massage knowing that it will not do any physical or mental harm to me. It is clear to

me that massage is not a substitute for any medical examination or diagnosis and that it is recommended that I see a physician for

any physical or mental ailment I may have. I understand that this massage is in NO WAY sexual and if insinuated I will be asked

to leave immediately and will pay for the full amount of the session.

Signature: ____________________________________________Date:____________________________________

One Woman Spa Massage Health Intake Form

Related Articles

Related forms

Related Categories