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                                       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

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Peace of Life Massage    211 E. Southlake Blvd., Ste. 114,   Southlake, TX 76092    email: ingrid@peaceoflifemassage.com    214-560-4600





211 E. SOUTHLAKE BLVD., STE. 114
SOUTHLAKE, TX 76092

This website is presented for information only and does NOT offer medical advice. Please consult your doctor regarding medical matters.