Massage Therapy Intake & Policy Form - Thai Wellness Center
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2Thai Wellness Center
MASSAGE THERAPY INTAKE & POLICY FORM
8290 Old Courthouse Rd, Suite D, Vienna, VA 22182
Name (please print):
___________________ DOB (Month/Day): _____________
Cell Phone: (
)
___
___ Work Phone: (
)
____________ Home Phone: (
)
E-mail address: __
_______
Address:
City:
State:
Zip:
Referred by:__
_____Have you ever had a professional massage before?
________
If so, how often?
Do you exercise?
Frequency:
Please describe type(s) of exercise:
Other daily activities:
Occupation:
Primary Care Physician:
Chiropractor:
How often do you relieve stress or pain with massage, stretching and/or yoga? _____
_______
What are the reasons for your visit today?
What are your other health concerns?
Describe any surgeries you have had:
Describe any physically damaging accidents you have had:
List all conditions currently monitored by a Health Care Provider:
List all medications that you’ve taken today and/or take regularly:
PLEASE NOTE ALL CURRENT AND PREVIOUS CONDITIONS BELOW AND DESCRIBE ANY CONDITIONS INDICATED
Headache
Y
N
Stiff/painful joints
Y
N
Sleep problems
Y
N
Neck, shoulder or arm pain or numbness
Y
N
Fatigue
Y
N
Low back, hip or leg pain or numbness
Y
N
Flu or cold symptoms in the last 48 hours
Y
N
Sciatica
Y
N
Sinus
Y
N
Depression
Y
N
Allergies to scents or lotions
Y
N
Blood clots
Y
N
Allergies, in general
Y
N
Stroke
Y
N
Arthritis
Y
N
Heart disease
Y
N
Osteoporosis
Y
N
High/low blood pressure
Y
N
Scoliosis
Y
N
Poor circulation
Y
N
Broken bones
Y
N
Asthma
Y
N
Disc problems
Y
N
Thyroid dysfunction
Y
N
Spasms/cramps
Y
N
Diabetes
Y
N
TMJ (jaw pain)
Y
N
Currently pregnant (how many months?)
Y
N
Tendonitis/Bursitis
Y
N
Malignant cancer or tumors
Y
N
Spinal problems
Y
N
Benign cancer or tumors
Y
N
Varicose veins
Y
N
I understand that the massage/bodywork I receive is provided for the purpose of relaxation & relief of muscular tension. If I experience any pain or discomfort during
this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage
or bodywork 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 of which I am aware. I understand that the massage/bodywork practitioners 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. Lastly I have read, understand and accept the appointment policies printed on the opposite side of this form.
Client Signature:
Date:
Practitioner Signature:
Date:
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