Medical Intake

* Indicates required field

Name *

First

Last

Phone Number *

Email *

Date of Birth *

Have you experienced a professional massage before? *

Yes No

Allergies *

Occupation *

Hobbies *

Other *

Are you pregnant? *

Yes No

If yes, when is your due date? *

List any medications you may be taking and what they are treatment for *

What brings you in today? *

Draping will be used during the session – only the area being worked on will be uncovered. Clients under the age of 18 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 18. No sexual discourse or overtures of any kind will be tolerated. I understand that the massage I receive is non-sexual and 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 and that I should see a qualified medical provider for any ailment that I am aware of. 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 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. *

I agree I do not agree

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Medical History Intake