Have You Ever Had a Massage Before? Yes No If Yes, When Was Your Last Massage? ______

Name: ______

Occupation: ______

DOB : ______

Have you ever had a massage before? Yes No If yes, when was your last massage? ______

If you are currently experiencing discomfort, where do you feel it in your body? (Please circle areas below)

Why do you think it hurts? (sitting all day, working out, heavy lifting on the job, etc. )
______

Have you ever been diagnosed with any of the following? Please check all that apply.

__ Heart Disease

__ High Blood Pressure

__ Cancer

__ Lupus

__ Diabetes

__ Depression/Anxiety

__ Insomnia

__ Migraine Headaches

__ Adrenal Fatigue/Chronic Exhaustion

__ IBS

__ GERD

__ HIV/AIDS

__ Strains/Sprains

__ Broken Bone (which one?) ______

__ Other (Please list below)

______

Are you currently taking any prescription or OTC medications? Yes No

If so, please list all medications you are taking and their intended purpose.
______

Have you ever had any surgeries? Yes No If yes, please list here: ______

Do you have any allergies or aversions to oils, nuts, or fragrances? Yes No

If yes, please list here: ______

Are you pregnant? Yes No Due Date: ______

Because of our high demand, we request the courtesy of a 24 hour cancellation notice. Cancellations made less than 24 hours in advance and NCNS (no call no shows) will be charged the full service price. Clients who reschedule their original service more than once will be subject to a $10 rescheduling fee for each subsequent rescheduling.

___ I have read these terms and conditions and I agree to adhere

I understand that I will be receiving massage therapy for the purpose(s) of pain management, stress relief, or improved circulation ONLY. I understand that massage therapists in this state shall not perform services of a sexual nature and should I attempt to solicit such services from my massage therapist, s/he reserves the right to immediately terminate the session and still receive payment in full.
___ I have read these terms and conditions and I agree to adhere
I understand that my massage therapist is not a diagnostician and as such cannot prescribe medical treatments/prescriptions, nor perform spinal manipulations. I understand that should I feel the need for such treatments, I will be encouraged to seek out accredited medical practitioners for the purpose of medical examination and subsequent diagnosis. I understand that I am receiving massage therapy at my own risk, and should I become injured either directly or indirectly as a result of of my massage session for reasons I have failed to disclose in this intake, I hereby hold harmless and indemnify my massage therapist from any claims or litigation whatsoever.

__ I have read these policies and I agree to adhere

Signature: ______Today’sDate: ______