Harmony Massage Therapy Intake Form printable pdf download

Harmony Massage Therapy Intake Form

Full Name: ________________________________Date of Birth:_________________

Address: _______________________________________________________________

City: __________________________ State: ___________

Zip: ______________

Phone: (h) ___________________ (c) ____________________

Email: _______________________ Occupation: ____________________________

How did you hear about Harmony Massage? _______________________________________

Emergency Contact: ____________________________________Phone: __________________

Primary Care Physician: ________________________________ Phone: ___________________

MEDICAL HISTORY

Medications (including vitamins/herbs): ______________________________________________

Please circle if you have or have had any of the following:

Headaches

allergies

arthritis/tendonitis

Cancer

TMJ

abnormal skin condition

Heart/circulation problems

high/low blood pressure

varicose veins

blood clots

Neck/back injuries

diabetes

fibromyalgia

Numbness/tingling

sprains/strains

recent injuries

Explain any conditions marked above: ______________________________________________

The above information is accurate and true to the best of my knowledge. I understand that massage

therapists do not diagnose disease, prescribe medications or manipulate bones. I further understand

that massage therapy is not a substitute for medical attention or examination; rather, it is a form of

health and wellness utilizing various techniques and modalities. I take responsibility for alerting my

therapist to any physical, mental or emotional changes that could affect this work.

Signature: _________________________________________ Date: _________________________

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Harmony Massage Therapy Intake Form