Client Intake Form - Therapeutic Massage Page 2
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1
2Medical 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
No
If yes, please explain___________________________________________________________________________________________
12. Do you see a chiropractor?
Yes
No
If yes, how often? _________________________________________________
13. Are you currently taking any medication?
Yes
No
If yes, please list ______________________________________________________________________________________________
14. Please check any condition listed below that applies to you:
Contagious skin condition
Phlebitis
Open sores or wounds
Deep vein thrombosis/blood clots
Easy bruising
Recent accident or injury
Joint disorder/rheumatoid arthritis/osteoarthritis/tendonitis
Osteoporosis
Recent Fracture
Epilepsy
Recent surgery
Headaches/migraines
Artificial joint
Cancer
Sprains/strains
Diabetes
Swollen glands
Back/neck problems
Allergies/sensitivity
Fibromyalgia
Heart Condition
TMJ
High or low blood pressure
Carpal tunnel syndrome
Circulatory disorder
Tennis elbow
Varicose veins
atherosclerosis
Pregnancy If yes, how many months?
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 (ex. Surgery or Car accident) ?
______________________________________________________________________
__________________________________________________________________________________________________________
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,___________________________________________ (print name) 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, chiropractor 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.
Signature of Client _________________________________________________ Date _______________________
Signature of Massage Therapist _______________________________________________ Date _________________
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