Moasis Therapeutic Massage Client Intake Form

Moasis Therapeutic Massage
Client Intake Form

Personal Information:

Name Date of First Visit

Cell Phone Home Phone Work Phone

Address

City/State/Zip

Email Date of Birth Occupation

Emergency Contact Phone

How did you hear about us?

Referral from:    Website    Gift Certificate

Location    Advertisement:

The following information will be used to help plan safe and effective massage sessions.

Please answer the questions to the best of your knowledge.

1. Have you had a professional massage before? Yes No

If yes, how often do you receive massage therapy?

2. Do you have any difficulty lying on your front, back, or side? Yes No

If yes, please explain

3. Do you have any allergies to oils, lotions, or ointments? Yes No

If yes, please explain

4. Are you wearing contact lenses ( ) a hearing aid ( ) ?

Contact lenses    Hearing aid

5. Do you sit for long hours at a workstation, computer, or driving? Yes No

If yes, please describe

6. Is there a particular area of the body where you are experiencing tension, stiffness, pain or other discomfort? Yes No

If yes, please identify

7. Do you have any particular goals in mind for this massage session? Yes No

If yes, please explain

Circle any specific areas you would like the massage therapist to concentrate on during the session:

[Body diagram area as shown on page 1]

Medical History - In order to plan a massage session that is safe and effective, I need some general information about your medical history.

8. Are you currently under medical supervision? Yes No

If yes, please explain

9. Do you see a chiropractor? Yes No If yes, how often?

10. Are you currently taking any medication? Yes No

If yes, please list

11. Any recent surgeries? Yes No

If yes, please explain

12. Please check any condition listed below that applies to you:

contagious skin condition
open sores or wounds
easy bruising
recent accident or injury
recent fracture
recent surgery
artificial joint/pins
sprains/strains
current fever
sciatica
allergies/sensitivity
heart condition
high or low blood pressure
circulatory disorder
varicose veins

edema/swelling
deep vein thrombosis/blood clots
joint disorder/rheumatoid arthritis/osteoarthritis/tendonitis
osteoporosis
epilepsy/seizures
headaches/migraines
cancer
diabetes
numbness/tingling
back/neck problems
Fibromyalgia
TMJ/jaw pain
carpal tunnel syndrome
multiple sclerosis
pregnancy - If yes, how many weeks?

Please explain any condition that you have marked above

13. Is there anything else about your health history that you think would be useful for your massage practitioner to know to plan a safe and effective massage session for you?

Clients under the age of 17 must be accompanied by a parent or legal guardian during the entire session.

Informed written consent must be provided by parent or legal guardian for any client under the age of 17.

I, (print name) understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so.

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