Massage Therapy Intake Form - Integrative Bodywork & Massage Page 2
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3Intake Form – Page 2 of 2
Please check any of the following that apply to you in the past or present:
Condition/Complaint
Yes
No
Condition/Complaint
Yes
No
Headaches
Pins and Needles in arms, legs,
Type:
Hands or feet
Asthma
Neurological problems
Cold Hands/feet
Spinal Problems
Swollen ankles
Herniated/Bulging Discs
Sinus Conditions
Osteoarthritis
Frequent Colds
Arthritis
Allergies (specify above)
Anxiety
Loss of smell/taste
Depression/Panic
Skin Conditions
Sleep Disturbance
Painful/Swollen Joints
Loss of Memory
Auto-immune disorder
Whiplash
Cancer
Bruise Easily
Varicose Veins
Constipation/Diarrhea
Blood Clots/DVT
Injuries
Heart Problems
Recent Surgeries
Pacemaker
Hemorrhoids
High/Low BP
Artificial/Missing limbs
Diabetes
Muscular Tension
Epilepsy or Seizures
Sciatica
Fainting Spells
Ticklish
Further explanation of any condition or other information:
What specific areas would you like for to focus on? ____
____________
Are there any areas you do NOT like massaged? (i.e. feet, stomach, head, face)?____________
The following sometimes occurs during massage; they are normal responses to relaxation. Trust your body to
express what it needs:
Need to move or change positions
Sighing, yawning, change in breath
Stomach gurgling
Emotional feelings and/or expressions
Movement of intestinal gas
Energy shifts
Falling asleep
Memories
•
I understand the treatment here is not a replacement for medical care.
•
As such, the therapist/practitioner does not prescribe medical treatment of pharmaceuticals, nor does he/she perform
any spinal manipulations (unless specified under his/her professional scope of practice)
•
I understand that the treatment is not a substitute of medical treatments and/or diagnosis and it is recommended that I
see a qualified professional for any physical or mental conditions that I may have.
•
I have stated all my known conditions and take it upon myself to keep the therapist/practitioner updated on my health.
•
I understand that payment is due at the time of treatment unless arrangements have been made otherwise.
•
I understand that therapist/practitioner shall not engage in breast massage of female clients without the written consent
of the client.
•
I understand that draping will be used during the session, unless otherwise agreed to by both the client and the
therapist/practitioner.
•
I understand that if uncomfortable for any reason, the client or the therapist/practitioner may ask to cease the massage
and end the session.
Client signature___________________________________________________Date____________________________
Therapist/practitioner ______________________________________________Date____________________________
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