Massage Intake - Patient Information Form Page 3

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Massage Intake
Nervous System
Skin
Reproductive
Shingles
Allergies__________
Pregnant: Stage__________
Numbness/tingling
Rashes
Ovarian/Menstrual Issues
Numbness/tingling
Athletes Foot
Prostate problems
Pinched Nerve
Herpes/Cold Sores
Other____________________
Other______________
Other_____________
Digestive
Other
Irritable Bowel Syndrome
Cancer/Tumors
Migraines/Headaches
Ulcers
Bladder/Kidney Ailment
Anxiety/Stress Syndrome
Other______________
Diabetes
Depression
Drug/alcohol use
Contact Lenses (hard or soft)
Caffeine use
Sleep Disorder
Tobacco use
Chronic Pain
Additional remarks/comments: _______________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
I have completed this form to the best of my knowledge and will inform the massage therapist of
any changes in my physical health. I understand that a massage therapist cannot diagnose illness,
disease or any other medical, physical, or emotional disorders, 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, they 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 original scheduled time so the client following me is not penalized. I agree to give
24-hour notice for a scheduled session that I cannot keep. I am aware that I may be charges the full
fee for any missed sessions or for the sessions that I do not give 24-hour notice to cancel or
reschedule.
_________________________________________________________________________________
Printed Name of Patient
Signature of Patient
Date
_________________________________________________________________________________
Printed Name of Guardian
Signature of Guardian
Date
PATIENT NAME:__________________________________________________________
PATIENT DOB:____________________________
KWAN-YIN HEALING ARTS CENTER
2330 NW FLANDERS ST. SUITE 101
PORTLAND, OR 97210
PH: 503.701.8766
FAX: 503.241.5484

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