Massage Therapy Intake Form

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Massage Therapy Intake Form

  • Date Format: DD slash MM slash YYYY
  • Date Format: DD slash MM slash YYYY
  • Please enter a number from 1 to 100.
  • What is your daily intake of:

  • Please check any of the following that apply to youin the past or present:

  • The following sometimes occurs during massage; they are normal responses to relaxation. Trust your body to express what it needs:

    • Need to move or change positions
    • Sighing, yawning, change in breath
    • Stomach gurgling
    • Emotional feelings and/or expressions
    • Movement of intestinal gas
    • Energy shifts
    • Falling asleep
    • Memories
    • I understand the treatment here is not a replacement for medical care.
    • As such, the therapist/practitioner does not prescribe medical treatment of pharmaceuticals, nor does he/she perform any spinal manipulations
    • I understand that the treatment is not a substitute of medical treatments and/or diagnosis and it is recommended that I see a qualified professional for any physical or mental conditions that I may have.
    • I have stated all my known conditions and take it upon myself to keep the therapist/practitioner updated on my health.
    • I understand that payment is due at the time of treatment unless arrangements have been made otherwise.
    • I agree to give at least 24 hours notice of cancellation of appointment, otherwise will be expected to pay for session
  • Date Format: DD slash MM slash YYYY