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MASSAGE INTAKE FORM

CLIENT INFORMATION

CLIENT INFORMATION

First Name

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Last Name

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Email

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Street Address

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City

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State

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Zip Code

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Phone

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DOB

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Age

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Emergency Contact

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Phone

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Occupation

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Referred by

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HEALTH INFORMATION

HEALTH INFORMATION

Are you taking any medications?

Yes

No

Please select an option.

If yes, please list:

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Any allergies? (oils, lotions, nuts, fruits, skin, etc.)

Yes

No

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If yes, please list:

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Are you pregnant?

Yes

No

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If yes, how many months:

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Due date

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Are you currently under medical supervision or other medical interventions?

Yes

No

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If yes, please describe:

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Areas of broken skin? (e.g., rash, wounds)

Yes

No

Please select an option.

If yes, where?

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History of joint replacement surgery?

Yes

No

Please select an option.

If yes, which joint(s)?

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Do you have any of the following? (check all that apply)

Areas of swelling

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Diabetes

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Osteoporosis

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Autoimmune disorder

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Fibromyalgia

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Phlebitis

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Back / neck problems

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Headaches

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Sciatica

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Bleeding disorders

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Heart condition

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Seizures

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Blood clots

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Hypertension

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Stroke

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Bruise easily

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Kidney disease

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Tendinitis

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Bursitis

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Multiple sclerosis

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TMJ disorder

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Cancer

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Neurological condition

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Varicose veins

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Contagious condition

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Neuropathy

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Vertigo / dizziness

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Decreased sensation

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Osteoarthritis

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Others:

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Recent injuries or medical procedures in the past 2 years?

Yes

No

Please select an option.

If yes, please describe:

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Please describe any other injuries or health conditions:

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MASSAGE INFORMATION

MASSAGE INFORMATION

Have you had a professional massage before?

Yes

No

Please select an option.

How recently?

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Reason for seeking massage:

Relaxation

Specific problem

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How much pressure do you prefer?

Light

Medium

Firm

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Please list and describe any areas of discomfort:

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ACKNOWLEDGMENT & RELEASE

ACKNOWLEDGMENT & RELEASE

By signing below, I acknowledge that I am aware of the benefits and risks of massage therapy and that I have completed this form to the best of my knowledge. I also agree to inform the therapist of any health conditions and/ or medical changes.

CLIENT SIGNATURE

CLIENT SIGNATURE

Print Name

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Date

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Please sign your name in the area below

By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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901 6th St, SW, Lobby Level,
Washington, DC 20024-3850

(202) 646-0100 Appointments

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