Custom Touch Massage Therapy Intake Form

Custom Touch Massage Therapy Intake/Release Form

408-739-4912

Name:_____________________________________

Address:___________________________________

City: ______________________________________

Daytime Phone Number:_______________________

Cell Phone Number: __________________________

Age:___________________________________

Birthdate:_______________________________

Wt: __________ Ht. ____________

Referred By:_____________________________

In Case of Emergency, please contact:

Name:_____________________________________

Phone Number:_______________________

General Medical Information:

Yes	No
		Have you ever had a professional massage/bodywork session?
		Do you frequently suffer from stress?
		Do you experience frequent headaches?
		Are you pregnant?
		Are you wearing contact lenses?
		Are you diabetic?
		Do you have high blood pressure? If yes, are you taking medication? _________________
		Are you epileptic?

If you answer YES to any questions in the section below, please write an explaination after the question.

Yes	No
		Is there a purpose for today’s session?
		Are you currently under the care of a Chiropractor? Who? How Often?
		Are you having any discomfort? On a level of 1-10 (1 = minor 10 = extreme), please rate your discomfort.
		Is your condition aggravated by certain activities? What type? What alleviates your discomfort?
		Do you have tension in your body? Where do you feel you hold it?
Yes	No
		Do you exercise? How often and at what intensity?
		Do you drink water during the day? How much?
		Are you allergic to any lotions or oils? What kind?
		Have you had any injuries in the past 5 years (car accidents, broken bones, etc.)?
		Do you have any serious health problems or medical conditions I should be aware of?

Please take a moment and carefully read the following information, and sign where indicated.

I, ____________________________, understand that the massage/bodywork I receive is provided for the basic purpose of relaxation, stress reduction, and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort.

I further understand that massage/bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment, and I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment that I am aware of.

Because massage/bodywork is contraindicated (should not be done) under certain medical conditions, I affirm that I have stated all known medical conditions, and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile, and understand that there shall be no liability on the practitioner’s part should I forget to do so.

_____________________________________
{Client Signature}

_____________________________________
{Massage Therapist Signature}

_____________________________________
{Date}