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Massage Intake Form - CONFIDENTIAL INFORMATION WELCOME I would like to make your appointment as pleasant and comfortable as possible. If at any time you have questions regarding your session please let me know. Name Date of birth Address State City Home Phone Work Phone Occupation Have you ever received massage therapy Yes No Type of massage experienced swedish shiatsu deep tissue etc* Are you currently taking any medications If yes please list name and reason for medications Please review this list and check those conditions that have affected your health either recently or in the past. Place a check mark next to the condition* arthritis diabetes blood clots broken/dislocated bones bruise easily cancer chronic pain constipation/diarrhea auto-immune condition hepatitis A B C other skin conditions stroke surgery TMJ disorder depression panic disorder other psych condition diverticulitis headaches heart conditions back problems high blood pressure insomnia muscle strain/sprain pregnancy scoliosis seizures whiplash chemical dependency alcohol drugs AIDS fibromyalgia chronic fatigue lupus etc* If any of the above needs to be detailed or if there is anything else to share please do so Do you have any of the following today skin rash cold/flu anything contagious open cuts severe pain injuries/bruises Do you have any allergies to medications foods nuts etc* environmental allergens dust pollen fragrances reactions to skin care products Are you wearing contact lenses hearing aid hairpiece Please indicate with an X if any the areas in which you are feeling discomfort What are your goals/expectations for this therapy session The following sometimes occurs during massage. They are normal responses to relaxation* Trust your body to express what it needs to need to move or change position sighing yawning change in breathing stomach gurgling emotional feelings and/or expression movement of intestinal gas energy shifts falling asleep memories Please read the following information and sign below 1. I understand that although massage therapy can be very therapeutic relaxing and reduce muscular tension it is not a substitute for medical examination diagnosis and treatment. 2. This is a therapeutic massage and any sexual remarks or advances will terminate the session and I will be liable for payment of the scheduled treatment. 3. Being that massage should not be done under certain medical conditions I affirm that I have answered all questions pertaining to medical conditions truthfully. If at any time you have questions regarding your session please let me know. Name Date of birth Address State City Home Phone Work Phone Occupation Have you ever received massage therapy Yes No Type of massage experienced swedish shiatsu deep tissue etc* Are you currently taking any medications If yes please list name and reason for medications Please review this list and check those conditions that have affected your health either recently or in the past. Place a check mark next to the condition* arthritis diabetes blood clots broken/dislocated bones bruise easily cancer chronic pain constipation/diarrhea auto-immune condition hepatitis A B C other skin conditions stroke surgery TMJ disorder depression panic disorder other psych condition diverticulitis headaches heart conditions back problems high blood pressure insomnia muscle strain/sprain pregnancy scoliosis seizures whiplash chemical dependency alcohol drugs AIDS fibromyalgia chronic fatigue lupus etc* If any of the above needs to be detailed or if there is anything else to share please do so Do you have any of the following today skin rash cold/flu anything contagious open cuts severe pain injuries/bruises Do you have any allergies to medications foods nuts etc* environmental allergens dust pollen fragrances reactions to skin care products Are you wearing contact lenses hearing aid hairpiece Please indicate with an X if any the areas in which you are feeling discomfort What are your goals/expectations for this therapy session The following sometimes occurs during massage. .

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