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

PLEASE LIST ANY RECENT INJURIES OR SURGERIES WITHIN THE PAST 5 YEARS: ____

_________________________________________________________________________________

PLEASE LIST YOUR STRESS-REDUCTION ACTIVITIES, HOBBIES, EXERCISE, AND/OR

SPORTS PARTICIPATION: ________________________________________________________

_________________________________________________________________________________

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.

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 massage/bodywork I receive is for the purpose of stress reduction, and relief from

muscular tension, spasm, or pain and to increase circulation. If I experience any pain or discomfort, I will

immediately inform my massage therapist so that the pressure and/or methods can be adjusted to comfort

level. I understand that my massage therapist does not diagnose illness or disease, nor perform any spinal

manipulations, and does not prescribe 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 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