Confidential Massage Therapy Intake Form

Name: _________________________________________________Date: __________________________

Address: _______________________________City: ____________ State:_______ Zip: ______________

Home Phone: ________________ Work Phone: ________________ Alt. Phone: ____________________

Male/Female

Single/Married/Divorced/Widowed

Birthdate: ___/___/___

Who referred you? _________________________ Have you ever had a massage before? Y/N

Occupation: ___________________________________________________________________________

Medical History

Approx. Weight: _______ Height: _______ Allergic to oils? Y/N Fragrances? Y/N

List any injuries, surgeries, or broken bones & when they occurred: _______________________________

_____________________________________________________________________________________

Please circle any of the following conditions you are experiencing :

Emotional Changes

Headaches

Skin Disorders

Hypoglycemia

Phlebitis

P.M.S. Syndrome

Heart Ailment

Diabetes

Pregnancy

Infectious Condition

Sleeplessness

Flu/Cold/Fever

Kidney Ailment

T.M.J. Syndrome

Varicose Veins

Cancer

Allergies

High Blood Pressure

Chronic/Acute Pain

Digestive Problems

Arthritis

Neck/Spine Injury

Ulcerated Colon

Osteoporosis

Fibromyalgia

Joint Discomfort

Carpel Tunnel Syndrome

Are you currently under the care of a health professional? Y/N Why? ____________________________

_____________________________________________________________________________________

Healthcare provider’s name and specialty: ___________________________________________________

List any medications:____________________________________________________________________

What types of exercise/stretches do you do and how often? ______________________________________

_____________________________________________________________________________________

I understand if I experience any pain or discomfort during my session(s), I will immediately inform the therapist so the pressure and/or strokes

may be adjusted to my level of comfort. I further understand that massage/bodywork should not be construed as a substitute for medical

examination, diagnosis, or treatment and I should see a physician, chiropractor or other qualified medical specialist for any mental or physical

ailment I am aware of. I understand massage therapists are not qualified to perform spinal or skeletal adjustments, diagnosis, prescribe, nor treat

any physical or mental illness, and nothing said in the course of the session(s) given should be construed as such. Because massage/bodywork

should not be done under certain medical conditions, I affirm I have stated all my known medical conditions, and answered all questions

honestly. I agree to keep the practitioner updated as to any changes in my medical profile, and understand there shall be no liability on the

practitioner’s part should I forget to do so. It is also understood any illicit or sexual suggestive remarks or advances made by me will result in

immediate termination of the session.

Client Signature __________________________________________________________

Please give 24 hour notice for cancellations.

Confidential Massage Therapy Intake Form - Essential Massage

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