Massage Intake Form - Healthy You Massage

Massage Intake Form
Date___/___/______
In order to provide you with the best quality massage, please complete this form in its entirety. All information is strictly confidential.
Client Name:______________________________________________________ Date of Birth___/___/______
Address:_____________________________________________________________________Age:_______
City:_______________________________________ State: __________ Zip Code: ________________
Email:_______________________________________________________________
Phone (Home)_________________________________ Phone (Cell) __________________________________
Occupation:____________________________________ Employer:______________________________________
Referred By(how did you hear about us): _______________________________________________________________
Emergency Contact
Name:_____________________________________________
Relationship:______________________________
Phone:_____________________________________________
Please list your primary health care professionals and their phone numbers:
(MD, Chiropractor, Osteopath, Nurse Practitioner, Naturopath, etc)
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Are you involved in any other therapies at this time? If so, what and how often?
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Are you currently taking any medications? For what Purpose? Please list:
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Have you Received massage therapy before? Yes__ No__
Do you wear contacts? Yes___ No___
Are you Pregnant? Yes___ No___ If so, how many months? ______ Dentures? Yes___ No___
Please explain any tension, pain, stiffness,
Numbness, tightness or discomfort you may
be experiencing and please indicate on the
body to the left with XXX were it is occurring.
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Health History
Please check any of the following health challenges you have experienced,
even if they do not seem related to your current health problem…
Musculoskeletal
Nervous System
Stroke
Cerebral Palsy
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Rheumatoid Arthritis
Digestive
Twitching
Plantar Fasciitis
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Scoliosis
Joint Stiffness
Problems walking
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Respiratory
PTSD
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Skin
us
ermatitis/Eczema
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Circulatory
Low Blood pressure
Heart Condition
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Other
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Please list any additional comments regarding your health and well-being:_________________________
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Please read and sign
Informed Consent
Massage is intended to enhance relaxation, reduce pain caused by muscle tension, increase range of
motion, improve circulation, and offer a positive experience of touch. If I experience any pain or
discomfort during any session, I will immediately inform the practitioner so that the pressure
and/or techniques may be adjusted to my level of comfort. In addition, if I am uncomfortable for
any reason, I may ask the massage therapist to stop the massage and the session will be ended.
I understand that massage therapists do not diagnose medical illness, disease, or any other physical
or mental conditions. I understand that massage 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. Because massage/bodywork should not be performed with the
presence of certain medical conditions, I affirm that I have stated all known medical conditions, and
answered all questions honestly. I agree to keep Healthy You Massage LLC updated as to
any changes in my medical profile and understand that there shall be no liability on the
practitioner’s part should I fail to do so.
Cancelation Policy
I understand that payment is due at the time of treatment unless arrangements have been made
otherwise. Because of this I require at least 24 hour notice on weekdays and 48 hour notice on Friday and
Saturday for cancellation of appointments. If I do not receive notice within this time period a fee of 50% will
be charged for the missed service. If there is a no show and no phone call we will charge a fee of
100% for the missed service. Cases of extreme emergence are considered exceptions to this
Cancellation policy.
Signature___________________________________________________________________________ Date____________