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Massage Therapy Intake Form

First Name *

Last Name *

Phone *

Email *

Address *

Street Address

City

State

Country

Postal Code

Date of birth *

Referred By

Date of Most Recent Physician Visit *

Symptoms

Reason for your visit today *

What activities improve/relieve symptoms? *

What activities aggravate/worsen symptoms? *

Is the condition related to

Have you previously received treatment for this condition?

Are you currently pregnant? If so, how many weeks?

ObGyn

Please list any current medications and/or nutritional supplements you are taking.

Please list ALL fractures/car accidents/ surgical operations with dates

Please check all that apply:

Allergies

Chest Pain

Anxiety

Arthirits/Osteoarthritis

Asthma/Difficulty Breathing

Back Pain

Cancer

Chronic Fatigue

C-Section/Hysterectomy

Depression

Defibrillator

Diabetes

Digestive Disorders

Edema/Swelling

Fibromyalgia

Fracture

Headaches

Heart Arrhythmia

Hearth Attack

Heart Disease

Hepatitis

Herniated Disk

Hernia

High Blood Pressure

Hip Pain

HIV

Joint Pain

Joint Replacement

Low Blood Pressure

Multiple Sclerosis

Neck Pain

Numbness

Overuse Injury

Pacemaker

Parkinson's Disease

Poor Circulation

Recent Surgery

Recent Injury

Rheumatoid Arthritis

Sciatic Pain

Seizures

Skin Disorders

Stress

Stroke

Thyroid Disease

TMJ Pain

Vertigo/Dizziness

Varicose Veins

Further explanation for any of the above:

Are you currently under a doctor's care for any condition not listed above

Please read and check the following:

I understand that this massage session is for therapeutic, relaxation, or stress reduction purposes only, and that NO claim to medical diagnosis or treatment is inferred or implied. Any information provided is for educational purposes only.

SPECIAL NOTE for Insulin Dependent Diabetics receiving Cranial Release Technique: I understand that I MUST and WILL monitor my blood sugar levels for at least the next 72 hours prior to every scheduled injection and/or oral medical ingestion.

I must communicate to my therapist any aggravation, injury or change in physical condition before each session

It is understood that any illicit or suggestive remarks or advances made will result in immediate termination of the session.

I release the therapist, Maureen Shaw, from any liability for pre-existing conditions or any consequential changes that arise subsequent to this or future treatments.

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

We require 24 hours notice, if a patient/client can not keep a scheduled office appointment. This allows us to accommodate other patients/clients. All patients/clients who cancel appointments with fewer than 24 hours notice will be subject to a $95 cancellation fee. Full amount will be charged for any no-shows. I have read and understand this policy.

Signature *

Clear

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