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M T & F: 9am - 5pm, W & Th: 1pm - 6pm

    Massage & Bodywork Intake Form

    *All information will be kept strictly confidential. Your responses will allow us to get a more complete picture of your health, uncover contributing factors to your chief complaint(s) and advise you in your health goals. Thank you for investing in your health. We look forward to supporting you!

    Birthdate








    Please mark all conditions, past and present, even if they are only occasional:

    Scoliosis/Spinal problems PastPresent
    Allergies/Sinusitis PastPresent
    Sciatica/Pinched Nerve PastPresent
    Colds/Flu PastPresent
    Arthritis/Gout PastPresent
    Asthma/Bronchitis PastPresent
    Numbness/tingling PastPresent
    Blood clots/Hypertension PastPresent
    Cold hands & feet PastPresent
    Diabetes PastPresent
    Twitches/Tremors PastPresent
    Cancer PastPresent
    Fibromyalgia PastPresent

    Heart disease PastPresent
    Headache/Migraine PastPresent
    Hepatitis/HIV PastPresent
    TMJ/Jaw pain PastPresent
    Lupus/Shingles PastPresent
    Menstrual problems PastPresent
    Eczema/Psoriasis PastPresent
    Pregnant PastPresent
    Chronic fatigue PastPresent
    Anxiety/Depression PastPresent
    Skin problems/sensitivities (please list below) PastPresent

    Please read the following:

    I have completed this form to the best of my ability and will inform the massage therapist of any change in my physical health.
    I understand that a massage therapist cannot diagnose illness, disease or any other mental, physical or emotional disorder, nor perform any spinal manipulations. I am responsible for consulting a qualified physician for any physical ailments that I have.
    I understand that massage therapy is a therapeutic health-aid and is non-sexual.
    I understand that if the massage therapist starts a session late, she will make it up to me at the end of my session if possible, or will reduce my fee accordingly. I understand that if I arrive late, my session will end at the originally scheduled time so the client following me is not penalized.
    I agree to give 24-hour notice for a scheduled session that I cannot keep. I am aware that I may be charged the full fee for any missed sessions or for sessions that I do not give 24-hour notice to cancel or reschedule.

    *Signature: