Peace of Life Massage
Intake Form
Name:___________________________________________________________ Date of Birth______________________
Address:_________________________________________________City___________________State/Zip___________
Phone: (Home)_______________(cell)_______________E-mail:______________________________________________
Areas of stress, pain, or tension:________________________________________________________________________
Please take a moment to carefully read the following questions. If you have a specific medical condition or specific symptoms, massage may be contraindicated. A referral from your primary care provider may be required prior to service being provided.
___Yes___No Have you ever experienced a professional massage?
___Yes___No Do you have cancer in your personal history?
___Yes___No Do you have hypertension? ___Yes___No Do you have diabetes?
___Yes___No Do you hypotension? ___Yes___No Are you pregnant?
___Yes___No Do you suffer from arthritis? ___Yes___No Are you wearing dentures?
___Yes___No Do you suffer from joint swelling? ___Yes___No Are you wearing contact lenses?
___Yes___No Do you have any contagious disease? ___Yes___No Do you have varicose veins?
___Yes___No Do you suffer from epilepsy or seizures? ___Yes___No Do you have osteoporosis?
___Yes___No Have you had any broken bones in the past 2 yrs? ___Yes___No Do you bruise easily?
___Yes___No Do you have spinal problems? ___Yes___No Do you have any allergies?
___Yes___No Have you been in an accident or suffered any injuries in the past 2 years?
Please list all medications along with the reason ____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Please list all other medical conditions:____________________________________________________________________________
Desired pressure: FIRM______ MED______ LIGHT______
Check the areas of your body that you give permission to receive massage:
___ back ___ legs ___ buttocks ___ arms ___ abdomen ___ chest ___ neck ___ head ___ face ___ feet ___ hands
Therapeutic breast massage will not be done . Draping will be used during the session. Parents or guardians of clients under the age of 17 must sign the Parent Consent form.
I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during the session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage 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 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.
___________________________________________________ _______________________________
Signature of Client Date
_________________________________________________________
Signature of Massage Therapist
Intake Form
Name:___________________________________________________________ Date of Birth______________________
Address:_________________________________________________City___________________State/Zip___________
Phone: (Home)_______________(cell)_______________E-mail:______________________________________________
Areas of stress, pain, or tension:________________________________________________________________________
Please take a moment to carefully read the following questions. If you have a specific medical condition or specific symptoms, massage may be contraindicated. A referral from your primary care provider may be required prior to service being provided.
___Yes___No Have you ever experienced a professional massage?
___Yes___No Do you have cancer in your personal history?
___Yes___No Do you have hypertension? ___Yes___No Do you have diabetes?
___Yes___No Do you hypotension? ___Yes___No Are you pregnant?
___Yes___No Do you suffer from arthritis? ___Yes___No Are you wearing dentures?
___Yes___No Do you suffer from joint swelling? ___Yes___No Are you wearing contact lenses?
___Yes___No Do you have any contagious disease? ___Yes___No Do you have varicose veins?
___Yes___No Do you suffer from epilepsy or seizures? ___Yes___No Do you have osteoporosis?
___Yes___No Have you had any broken bones in the past 2 yrs? ___Yes___No Do you bruise easily?
___Yes___No Do you have spinal problems? ___Yes___No Do you have any allergies?
___Yes___No Have you been in an accident or suffered any injuries in the past 2 years?
Please list all medications along with the reason ____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Please list all other medical conditions:____________________________________________________________________________
Desired pressure: FIRM______ MED______ LIGHT______
Check the areas of your body that you give permission to receive massage:
___ back ___ legs ___ buttocks ___ arms ___ abdomen ___ chest ___ neck ___ head ___ face ___ feet ___ hands
Therapeutic breast massage will not be done . Draping will be used during the session. Parents or guardians of clients under the age of 17 must sign the Parent Consent form.
I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during the session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage 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 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.
___________________________________________________ _______________________________
Signature of Client Date
_________________________________________________________
Signature of Massage Therapist
