Massage Therapy Client Intake Form Page 2
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1
2Medical 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
joint disorder/rheumatoid
arthritis/osteoarthritis/tendonitis
recent accident or injury
osteoporosis
recent fracture
epilepsy
recent surgery
headaches/migraines
artificial joint
cancer
sprains/strains
diabetes
current fever
decreased sensation ( ) back/neck problems
swollen glands
Fibromyalgia
allergies/sensitivity
TMJ
heart condition
carpal tunnel syndrome
high or low blood pressure
tennis elbow
circulatory disorder
pregnancy If yes, how many months?_____
varicose veins
atherosclerosis
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?
_______________________________________________________________________________________
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.
_____________________________________________________
___________________________
Patient Signature
Date
_____________________________________________________
___________________________
Massage Therapist Signature
Date
208 Washington Street | Jersey City, New Jersey 07302 | 201-333-FACE
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