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

Medical History

In order to plan a massage session that is safe and effective, we need some general information about your medical history.

11. Are you currently under medical supervision?

Yes

If yes, please explain________________________________________________________________________________

12. Do you see a chiropractor?

Yes

If yes, how often? __________________________________________________________________________________

13. Are you currently taking any medication?

Yes

If yes, please list ___________________________________________________________________________________

14. Please check any condition listed below that applies to you:

( ) phlebitis

( ) deep vein thrombosis/blood clots

( ) joint disorder/rheumatoid arthritis/osteoarthritis/tendonitis

( ) osteoporosis

( ) epilepsy

( ) headaches/migraines

( ) cancer

( ) diabetes

( ) decreased sensation

( ) back/neck problems

( ) Fibromyalgia

( ) TMJ

( ) carpal tunnel syndrome

( ) tennis elbow

( ) pregnancy If yes, how many months? _______

( ) contagious skin condition

( ) open sores or wounds

( ) easy bruising

( ) recent accident or injury

( ) recent fracture

( ) recent surgery

( ) artificial joint

( ) sprains/strains

( ) current fever

( ) swollen glands

( ) allergies/sensitivity

( ) heart condition

( ) high or low blood pressure

( ) circulatory disorder

( ) varicose veins

( ) atherosclerosis

( ) other ________________________________

Please explain any condition that you have marked above: ________________________________________________

__________________________________________________________________________________________________________

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

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

_______________________________________________________________________________________________________



Draping will be used during the session – only the area being worked on will be uncovered.



Clients under the age of 17 must be accompanied by a parent or legal guardian during the entire

session. Informed written consent must be provided by parent or legal guardian for any client under the

age of 17.

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 this 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, chiro-

practor or 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 spinal or skeletal 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.

How do you hear about us? ______________________________________________________________

Signature of client _________________________________________________________Date ________________________

Signature of Massage Therapist ____________________________________________Date _________________________

Client Intake Form - Therapeutic Massage Page 2

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