Client Intake Form - Massage Therapy (Page 2 of 2) in pdf

Do you exercise regularly? Y / N If so, what activities and how often?

________________________________________________________________________________________

Do you currently have or have you ever had any of the following: (please check)

__ heart condition

__ migraines

__ recent surgery

__ cancer

__ TMJ

__ allergies/sensitivity

__ fibromyalgia

__ epilepsy

__ artificial joint

__ skin condition/rash

__ carpal tunnel syndrome

__ diabetes

__ open sores/wounds

__ osteoporosis

__ easy bruising

__ back/neck problems

__ varicose veins

__ thyroid conditions

Please describe if any checked above: _________________________________________________________

________________________________________________________________________________________

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

_________________________________________________________________________________________

Is there anything else about your health history that you think would be helpful for your massage therapist to

know in order to plan a safe and effective massage for you?

_________________________________________________________________________________________

__________________________________________________________________________________________

I understand that the massage I receive is provided for the basic purpose of relaxation, relief of muscular

tension, and overall well being. 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 the level of my comfort. I further

understand that massage therapy should not be construed as a substitute for medical examination, diagnosis,

or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any

mental or physical ailment that I am aware of. I understand that massage therapists are not qualified to

perform spinal or skeletal 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. I assume full

responsibility for receipt of massage therapy; I release and discharge the practitioner from any and all claims,

liability, damages, actions or causes of actions arising from therapy received. I also understand that any illicit

or sexually suggestive remarks or advances made by me will result in immediate termination of the session,

and I will be liable for payment of the scheduled appointment. I understand that this consent form and waiver

of liability will apply to my current and future therapy sessions with therapists at Damselfly Yoga LLC dba

Damselfly YogaSpa. I consent to receive massage and bodywork from therapists at Damselfly YogaSpa.

Client printed name __________________________________ Date_____________________

Client Signature________________________________________________________________

Client Intake Form - Massage Therapy Page 2

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