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Carver, MA
(978) 500-1104
*BY APPOINTMENT ONLY*
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Client Intake Form
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The following information will be used to help plan safe and effective massage sessions. Please answer the questions to the best of your knowledge.
Date of Initital Visit
1. Have you had a professional massage before?
Yes
No
If yes, how often do you have massage therapy?
2. Do you have any difficulty lying on your front, back, or side?
Yes
No
If yes, explain.
3. Do you have any allergies to oils, lotions, or ointments?
Yes
No
If yes, explain.
4. Do you have sensitive skin?
Yes
No
If yes, explain.
5. Are you wearing contact lenses, dentures, or a hearing aid?
Yes
No
If yes, explain.
6. Do you sit for long hours at a workstation, computer, or driving?
Yes
No
If yes, explain.
7. Do you perform any repetitive movement in your work, sports, or hobby?
Yes
No
If yes, explain.
8. Is there a particular area of the body where you are experiencing tension, stiffness, pain or other discomfort?
Yes
No
If yes, explain.
9. Do you have any particular goals in mind for this massage session?
Yes
No
If yes, explain.
In order to plan a massage session that is safe and effective, we need some general information about your medical history.
10. Are you currently under medical supervision?
Yes
No
If yes, explain.
11. Have you had any recent surgeries/injections?
Yes
No
If yes, explain.
12. Are you currently taking any medication?
Yes
No
If yes, explain.
13. Please check any condition listed below that applies to you13. Please check any condition listed below that applies to you?
contagious skin condition
phlebitis
open sores or wounds
deep vein thrombosis/blood clots
easy bruising
joint disorder/rheumatoid arthritis/osteoarthritis/tendonitis
recent accident of injury
osteoporosis
recent surgery
epilepsy
artificial joint
headaches/migraines
sprains/strains
cancer
current fever
diabetes
swollen glands
decreased sensation
allergies/sensitivity
back/neck problems
heart condition
Fibromyalgia
high or low blood pressure
TMJ
circulatory disorder
carpal tunnel syndrome
varicose veins
tennis elbow
atherosclerosis
pregnancy
Please explain any condition that you have marked above.
14. Is there anything else about your health history that you think would be useful for your massage practitioner to know to plan a safe and effective massage session for you?
Terms
Please check box to acknowledge the following:
Draping will be used during the session – only the area being worked on will be uncovered. Informed written consent must be provided by parent or legal guardian for any client under the age 18.
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 this massage 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 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 during 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 understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session. I also understand that the Licensed Massage Therapist reserves the right to refuse to perform massage on anyone whom he/she deems to have a condition for which massage is contraindicated.
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