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

Massage Therapy Client Health Intake Form Page 2

Please use the letters provided in the key to identify the symptoms you are feeling today. Circle the area

around each letter, representing the size and shape of each symptom location.

P= pain or tenderness

S= joint or muscle stiffness

N= numbness or tingling

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 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