Massage Therapy Intake Form

Name

Phone Number

Have you had a professional massage before?

Yes

If yes, how often do you receive professional massages?

Do you have difficulty lying on your front, back, or side?

Yes

If yes, please explain

Do you have any allergies to oils, lotions, or aromas?

Yes

If yes, please explain

Do you have sensitive skin?

Yes

Are you wearing contacts?

Yes

Do you sit for long hours at a time at a workstation, desk, or driving?

Yes

If yes, please explain

Do you perform any repetitive movement in your work, sports or hobby?

Yes

If yes, please explain

Do you experience stress in your work, family, or other aspect of your life?

Yes

If yes, how do you think it has affected your health?

Muscle tension

Anxiety

Insomnia

Irritability

Other…

Is there any particular area of the body where you are experiencing tension?

Do you have any particular goals in mind for this massage?

Yes

If yes, please explain

Please list any areas of the body you want the massage therapist to focus on

Medical History

In order to plan a massage session that is safe and effective, we need some general information about your medical history.

Are you under the care of a medical professional? If yes, please explain

Do you see a chiropractor?

Yes

If yes, how often?

Are you currently taking any medications? Please list

Please explain any condition you have marked above

Are you currently pregnant? If so, how many months

Is there anything else about your health history that you think would be useful for your massage therapist to know?

Draping will be used during the session, only the area being worked on will be uncovered.

Clients under the age of 18 will need to have a parent or guardian present in the spa room unless a waiver has been
signed by guardian.

I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscle tension. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure 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, or medical specialist for any aliment that 1 am aware of. I understand massage therapists are not qualified to preform spinal or skeletal adjustments, diagnose, prescribe, or treat any illness. 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 there shall be no liability on the therapist part should I fail to do so.

Please input your full name to agree to the statements above.

Signature

Please use your mouse (or finger if on phone/tablet) to sign your name above.

Massage Therapy Intake Form

Medical History

Questions about how AL!VE can help you reach your goals? Get in touch.