Massage intake form

Name
Date
Address
Phone number(s)
Birthdate
Occupation
Email address
Have you ever had a massage before? No Yes

When and type of massage experienced :
What results would you like to see from your sessions?
Are there any areas of your body you would like to focus on or prefer be avoided?

Please include the names of any healthcare professionals you are currently seeing and reason/treatment.

Do I have permission to contact them concerning your current condition, if I feel that it is necessary for your safety? Yes No Only with my express consent, on a per-incident basis.

Are you currently taking any medications/supplements/herbs/homeopathic remedies?
No Yes   Which?

Please review this list and check those conditions that have affected your health either recently or in the past.

arthritis
diabetes
blood clots
broken/dislocated bones
bruise easily
cancer
chronic pain
constipation/diarrhea
auto-immune condition*
hepatitis (A, B, C, other)
skin conditions
stroke
surgery
TMJ disorder

 depression, panic disorder, other psych condition
headaches
heart conditions
back problems
high blood pressure
insomnia
muscle strain/sprain
pregnancy
scoliosis
seizures
whiplash
chemical dependency (alcohol, drugs)
(*AIDS, fibromyalgia, chronic fatigue, lupus, etc.)

Do you have any of the following today?:
skin rash
cold/flu
open cuts
severe pain
anything contagious
injuries/bruises

Do you have any allergies to:
medications
foods (nuts, etc.)
environmental allergens (dust, pollen, fragrances)
reactions to skin care products

If any of the above are checked, please give details:

Please read each statement before you submit this form.

 

All massage received will be therapeutic wellness massage, to promote relaxation and relieve discomfort caused by tension. The massage therapy and bodywork are not substitutes for medical examination or diagnosis and that it is recommended that I see a medical practitioner for any physical ailment that I may have. By signing I declare that, to the best of my knowledge, the above information is accurate and truthful. According to informed consent, I acknowledge that I am aware of the minor potential for soreness, bruising, or headaches in the days following a therapeutic massage. I also acknowledge that I am aware that any massage received will be non-sexual in nature. If, at any time, either client or therapist feels uncomfortable with the situation, the session may be terminated immediately. By submitting this form, I hereby waive and release Wellness Renewed in Hawaii and it’s staff, massage therapists, and bodywork practitioners from any and all liability, past, present, and future relating to massage therapy and bodywork.