Massage & Bodywork Intake Form

Are you allergic to nuts, seeds, avocado or any other items that may be present in massage oils?

Do you have any skin irritations or issues we should be aware of? (Acne, rashes, sensitivities, etc)

Have you had any major surgeries or injuries?

Are you currently under any medical treatment we should be aware of?

Are you currently taking any medications? (Please List)

List any exercise activities and frequency:

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:

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