Massage Therapy Client Health Intake Form (Page 2 of 2) in pdf

Massage Therapy Client Health Intake Form Page 2

Please list any injuries or surgeries in the pelvic region: _________________________________________________

_________________________________________________________________________________________________________

Please list your stress-reduction activities, exercise and frequency:______________________________________

______________________________________________________________________________________

I have stated all conditions that I am aware of and this information is true and accurate to the best of my knowledge.

I will inform my health care provider and massage therapist if anything changes in my status. I understand that

massage/bodywork I receive is for the purpose of stress reduction and the relief from muscular tension, spasm or

pain and to increase circulation. If I experience any pain or discomfort, I will immediately inform my massage

therapist so that the pressure and/or methods can be adjusted to my comfort level. I understand that my massage

therapist does not diagnose illness or disease, nor perform any spinal manipulations, and does not prescribe any

medications/treatments. I acknowledge that massage is not a substitute for a medical examination or diagnosis and

that I should see my health care provider for those services. If I am unable to attend my scheduled appointment, I will

respect and abide by the set cancellation policies. Sexual advances, request for sexual favors, and other verbal or

physical conduct of a sexual nature will constitute as sexual harassment and will not be tolerated. I understand that I

am receiving massage therapy at my own risk. In the event that I become injured either directly or indirectly as a

result, in whole or in part, of the aforesaid massage therapy I hereby hold harmless and indemnify the therapist, their

principals, and agents from all claims and liability whatsoever.

Client Signature: ________________________________________________ Date: _____________

Massage Therapy Client Health Intake Form Page 2