Glo Massage Intake Form Confidential Information Page 2
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2Intake Form – Page 2 of 2
Are there any areas you do NOT like massaged (i.e. feet, stomach, head, face)?
What do you hope to accomplish with this massage? (i.e. relaxation, decrease back pain, increase flexibility,
etc.)
How frequently and for how long do you exercise and what do you do? Include sports, Pilates, yoga, gardening
and/or other physical activities:
How many hours of sleep do you receive each night (approximately)?
What is your sleeping position?
Check one: Are you right-handed
or left-handed
What is your daily intake of: Water:
Caffeine:
Alcohol:
Please check any of the following that apply to you in the past or present::
Condition/Complaint
Past
Present
Condition/Complaint
Past
Present
Headaches
Pins and Needles in arms, legs,
Type:
Hands or feet
Asthma
Neurological problems
Cold Hands/feet
Spinal Problems
Swollen ankles
Herniated/Bulging Discs
Sinus Conditions
Osteoarthritis
Frequent Colds
Arthritis
Allergies (specify above)
Anxiety
Loss of smell/taste
Depression/Panic
Skin Conditions
Sleep Disturbance
Painful/Swollen Joints
Loss of Memory
Auto-immune disorder
Whiplash
Cancer
Bruise Easily
Varicose Veins
Constipation/Diarrhea
Blood Clots/DVT
Contact Lenses
Heart Problems
Dentures/Partials
Pacemaker
Hemorrhoids
High/Low BP
Artificial/Missing limbs
Diabetes
Muscular Tension
Epilepsy or Seizures
Sciatica
Fainting Spells
Further explanation of any condition or other information:
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 (unless specified under his/her professional scope of practice)
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 PLEASE INITIAL
Client signature___________________________________________________Date____________________________
Updated 0411
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