Name

First Name

Last Name

Occupation

Referred By

The following information will be used to help your therapist plan a safe and effective massage session. Please answer the questions to the best of your knowledge.

Have you had professional massage before?

If yes, how often?

Do you have any problem lying on you front, back or side?

If yes, please explain:

Do you have any allergies to oils, lotions, ointments, fruits or nuts?

If yes, please list here

Do you have senitive or reactive skin?

If yes, please explain:

Are you currently

wearing contact lenses

wearing dentures

wearing a hearing aid

have prosthetics

have implants:

port

stint

bone pins or bars

saline sacs

Do you sit for long hours at a work station, computure, or driving?

If yes, please describe:

Do you preform any repetive movement in your work, sports, or hobby?

If yes, please describe:

How do you feel stress affects your health? Examples - muscle tension, anxiety, insomnia, irritability, other. Please describe below:

Are there specific areas of the body you hold stress or feel tension, stiffness, pain or discomfort?

If yes, please identify and explain:

Do you have any particular goals in mind for this bodywork session?

If yes, please explain:

Please list the areas of your body you want consentrated attention on:

Please list the areas of your body you want avoided:

Section 1

Medical History

Are you currently pregnant?

Are you currently under medical supervision?

If yes, please explain

Do you currently see a chiropractor?

If yes, how often?

Are you currently taking any medications or suppliments?

If yes, please list here:

Section 2

I understand that the massage I receive is provided for the basic purpose of relaxation and releif of muscular tension. If I experience any pain or discomfort during my 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 substitue for medical examination, diagnosis, or treatment and that I should see a physician or other qualified medical specialist for any mental or physical aliment that I am aware of. I understand that massage therapists are not qaulified to perform 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 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. Please write your name and today's date to serve as your e-signature:

Please allow your therapist to review this form before submitting. Thank you.

Integrative Massage and Bodywork Intake Form