Confidential Health Intake Form

Name ______Date of Birth ______Email ______

Street Address/Apt Number:______

City______State______Zip______

Contact Phone Number______

Emergency Contact ______

Occupation/employer ______

Medical History and Information

List all medications/herbs/vitamins: ______

______

List previous major injuries/surgeries & dates: ______

______

What other treatments are you receiving and by whom (acupuncture, physical therapy, chiropractic, naturopathic)______

Any known allergies?______

Women only: ___Pregnant or trying to become pregnant

Check any or all that apply to your present health:

___ headaches___chronic pain ___varicose veins

___ vision problems___muscle or joint pain ___blood clots

___ sinus problems___numbness/tingling ___high/low blood pressure

___ jaw pain/teeth grinding___disc problems ___diabetes

___ fatigue___scoliosis ___cancer/tumors

___ depression___arthritis ___infectious disease

___ sleep difficulties___tendonitis ___skin problems

___ anxiety ___bruise easily ___carpal tunnel

___ fibromyalgia ___epilepsy or seizures ___sciatica

Smoking/alcohol/drug use:______Other ______

What movements or activities are limited? ______

What seems to help the most? ______

What do you want to get out of your session (s) ?______

______

Any areas that you do NOT want massaged? ______OVER

Mark your areas of concern on the body diagrams below.

Informed Consent

Please initial on provided line that you understand the below information

_____I understand the above information is strictly confidential and is used to help the massage therapist determine any indications or contraindication for massage.

_____Since massage is contraindicated for some serious medical conditions, it may be necessary to obtain a doctor’s release or prescription before beginning therapy.

_____ The above information is accurate to the best of my knowledge, and I freely give my permission to be massage.

_____I agree to update the massage therapist in regard to changes in my health and understand that there shall be no liability on the therapist’s part should I forget to do so.

_____I understand this does not deter me from seeking medical treatment for medical conditions.

_____I agree to inform the therapist of any experience of pain during the session.

_____I understand that no inappropriate comments or conduct will be tolerated. Any indication of such behavior will automatically end the session.

_____Should I have to cancel an appointment for any reason, I agree to give the therapist a 24-hour notice. Otherwise, a cancellation/no-show fee of up to $25 may apply.
_____I understand that gratuity is not included in the price of my massage.

Client signature: ______Date: ______

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Therapist Comments (ie. previous massage, likes and dislikes, type pressure preferred) ______

______

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revised 1/9/17