Massage Therapy Intake Form
Please help us provide you with a complete evaluation by taking the time to fill out this questionnaire carefully. All answers are confidential.
Emergency Contact Info:
If someone referred you to us, whom specifically may we thank?
*Have you ever had a professional massage or other type of bodywork? Yes No
If yes, when was your last session:
What results do you hope to achieve from receiving massage?
*Please choose your preference of having these areas massaged:
Indicate your current Stress Level from lowest (1) to highest (10):
*Do you smoke? Yes No
*Wear contact lenses? Yes No
*Wear dental pieces? Yes No
If you exercise or are active regularly, list what you do and how frequently:
*Are you presently under the care of a physician or therapist? Yes No
If so, for what?
*Are you allergic to any oils or nuts? Yes No
If yes, please specify:
List any other allergies and your reaction:
List any medication(s) or supplements you are presently taking and the reasons you are taking them.
List any side effects you may experience:
For women, is there a chance you are pregnant? Yes No
If so, how many weeks are you?
Is there anything else in terms of your health or well-being that you feel your therapist should know before you begin your session?
Please CHECK any of the following conditions you currently have or have experienced in the past.
Using the images above and letters below, please indicate which areas are of concern (for example pain and tenderness in the right area of the head would be notated by 1-O):
Pain and Tenderness = O
Numbness and Tingling = Z
Swelling and Stiffness = X
The information I have provided is true and correct to the best of my ability.
Massage Therapy - Informed Consent
- I hereby voluntarily consent to massage therapy.
- I understand that massage therapy is for the purpose of stress reduction, relief from muscular tension or spasm, for increasing circulation, energy flow and relief from stiff joints. The procedures have been fully explained to me.
- I understand that the massage therapist does not diagnose illness, disease, or any other conditions.
- I affirm that I have stated all my known medical conditions and answered questions honestly, since there may be possible contraindications with massage therapy. I agree to keep the massage therapist updated as to any changes in the above and void any liability on the therapist’s part should I forget.
- I understand both therapist and client have the right to terminate a session for any reason. The client is responsible for the fee of that scheduled appointment.
- Inappropriate sexual conduct will result in termination of the session with the client responsible for the fee of that scheduled appointment.
- I understand that no guarantees concerning its use and effects are given to me, and that I am free to stop massage therapy treatment at any time.
- I understand and agree that I am responsible for payment of all fees associated with treatment. If I am using health insurance or other third-party payment options, I understand that I am responsible for all fees that are not covered.
- I understand and agree to pay the full fee for appointments cancelled with less than 24 hours notice.
- I have carefully read and understand all the foregoing and so am fully aware of what I am signing. I have felt free to ask any questions.