Massage Intake Form

Please mark below a (C) for Current condition or (P) for Past condition
Headaches/migraines
Allergies
Neck Pain
Back Pain
Spinal column disorders
Sprains/strains
Muscle/joint pain
Muscle/bone injuries
Arthritis/tendonitis
Number/tingling
Heart/circulatory disorders
High/Low Blood Pressure
Blood thinners
Diuretics
Chronic pain
TMJ
Varicose/spider veins
Diabetes
Clotting disorders
Cancer/tumors
Asthma or Lung Conditions
Indigestion/Heartburn/Hernia
Constipation/diarrhea
Crones disease
Thyroid problems
Anxiety/Stress
Menupause
PMS
Insomnia
Sinus Problems
Pregnancies
Vision problems or contacts
Dental bridges, braces
Birth Control
Skin Conditions
Acne
Rashes
Cold sores
Rosacea
Claustrophobia
Light sensetivity (skin or eyes)
Other medical conditions not listed:
Please list all forms and frequency of stress reduction activities, hobbies, exercise or sports participation
It is important that you drink plenty of water after a massage. Massage promotes circulation of blood, lymph and in some cases intestinal matter. Water helps clear toxins and keeps you feeling your best. It is recommended that you drink half your body weight, daily, in ounces of water. This does not mean coffee, tea, soft drinks, etc.
Please take a moment and carefully read the following information, circle relationship to client and sign where indicated.
If you have a specific medical condition or specific symptoms, massage/bodywork may be contraindicated. A referral from your primary care provider may be required prior to services being provided. I understand that the massage/bodywork I receive is provided for the basic purpose of relaxation and relief of muscular tension. Because massage/bodywork is contraindicated (should not be done) 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 practitioner updated as to any changes in my medical profile.
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We want to give you the best treatment possible.

Please mark below a (C) for Current condition or (P) for Past condition

Please take a moment and carefully read the following information, circle relationship to client and sign where indicated.

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Massage Intake Form

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We want to give you the best treatment possible.

Please mark below a (C) for Current condition or (P) for Past condition

Please take a moment and carefully read the following information, circle relationship to client and sign where indicated.

Call Us

Email Us

Visit Us

Business Hours