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Massage-Policy-Notification.pdf
General Liability Release Form
Massage Guidelines
Hot Stone Massage Consent and Release Form
Massage Consent and Release Form
Intake Form
Client Information
First name
Last name
Email
Birthday
Month
Month
Day
Year
Address
Phone
Health Information
What brings you in today?
Please list three areas of the body where you are experiencing pain or discomfort. These areas are where we will focus our session.
Are there any particular modalities/ treatments that you would like to be incorporated into the session? If so, please list.
Are you taking any medications?
yes
no
If yes, please list:
Any allergies? (oils, lotions, nuts, fruits, skin, etc)
Yes
No
If yes, please list:
Are you Pregnant?
Yes
No
If yes, how many months?
Are you currently under medical supervision or receiving other medical interventions?
Yes
No
If yes, please describe:
Areas of swelling
Yes
No
If yes, where?
Autoimmune disorder
Yes
No
Back/neck problems
Yes
No
Blood Clots
Yes
No
Bleeding disorders
Yes
No
Bruise Easily
Yes
No
Bursitis
Yes
No
If yes, where?
Cancer
Yes
No
Contagious Condition
Yes
No
Decreased Sensation
Yes
No
If yes, Where?
Diabetes
Yes
No
Fibromyalgia
Yes
No
Headaches
Yes
No
Heart Condition
Yes
No
Hypertension
Yes
No
Kidney Disease
Yes
No
Multiple Sclerosis
Yes
No
Neurological Condition
Yes
No
Neuropathy
Yes
No
If yes, where?
Osteoarthritis
Yes
No
Osteoporosis
Yes
No
Phlebitis
Yes
No
Sciatica
Yes
No
Seizures
Yes
No
Stroke
Yes
No
TMJ Disorder
Yes
No
Is one side more symptomatic than the other? If so which one?
Tendinitis
Yes
No
If yes, where?
Varicose Veins
Yes
No
Vertigo / dizziness
Yes
No
Areas of broken skin? (rash, wounds)
Yes
No
If yes, where?
History of joint replacement surgery?
Yes
No
If yes, which joint(s) and when (Month/Year)?
Recent injuries or medical procedures in the last 2 years?
Please describe any other injuries or health conditions (Month/Year):
Massage Information
Have you had a professional massage before?
*
Yes
No
How recently?
What would make this appointment a success?
By signing below, I acknowledge that I am aware of the benifits and risks of massage therapy and that I have completed this form to the best of my knowledge. I also agree to inform my massage therapist of any health or medical changes
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Date
Month
Month
Day
Year
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