NAME_____________________________________ TEL#______________________________E-MAIL_______________________________

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ADDRESS__________________________________________________________________________________________________________

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CITY________________________________________ STATE_______________________________________ZIP_______________________

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__STUDENT __MALE __FEMALE    DATE OF BIRTH___________________ PHYSICIAN, IF REFERRED_________________________________

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OCCUPATION__________________________________________________HOW DID YOU HEAR FROM US?___________________________

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GENERAL AND MEDICAL INFORMATION

 

__YES __NO Have you ever experienced massage by a licensed massage therapist? How recently? ______________________________________

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DO YOU HAVE THE FOLLOWING CONDITIONS? IF CHECKED, PLEASE EXPLAIN BELOW AS CLEARLY AS POSSIBLE. 

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___ Stress                                                                   ___ Cardiac or circulatory problems                                 ___ Depression

___Allergies                                                               ___ Arthritis                                                                           ___ Numbness or stabbing pains

___Contagious disease                                            ___ Very sensitive to touch or pressure                                     Specify below

___Diabetes                                                               ___ Frequent headaches                                                     ___ Tension or soreness in a specific area?

___Wear contact lenses                                          ___ Osteoporosis                                                                           specify below.

___Back Pain                                                             ___ Epilepsy or seizures

___Pregnant                                                              ___ Bruise easily 

___Cancer                                                                  ___ Joint swelling 

___High blood pressure. If "Yes",                            ___Varicose veins

taking medication for this?                               

___Surgery in the past 5 years? 

explain below.

___Accident or suffered any injuries in 

the past 2 years? Broken bones, etc.

___Other medical conditions not listed

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SPECIFY BELOW. / LIST THE REASON FOR CHOOSING MASSAGE THERAPY AND WHAT RESULTS YOU EXPECT TO HAVE.

COMMENTS:

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The unclothed body will be properly draped at all times for your warmth, sense of security and as a mark of massage professionalism. 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.  I understand that massage therapists are not qualified to perform spinal or skeletal adjustments, diagnosis, 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 massage therapist updated as to any changes in my medical profile during the session and understand that there shall be no liability on the massage 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 he/she deems to have a condition for which massage is contraindicated.  I understand that by signing this form, I give my consent to receive the treatment in this and all future sessions and I agree that my presence and subsequent sessions shall be construed to be a validation of this written consent. 

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I HAVE READ THIS FORM AND HEREBY FREELY GIVE MY PERMISSION TO BE MASSAGED.

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CLIENT SIGNATURE:_________________________________________________________ DATE:_______________________________

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                                                                                                             ENJOY YOUR SESSION!