Massage Intake Form – Herbert Wellness Center We would like to make your appointment as pleasant and comfortable as possible. If at any time you have questions regarding your session, please let us know. Name ________________________________________________ Date of Birth __________________________ Street Address ______________________________________________________________________________ City ______________________ State ______ Zip/Postal Code ___________ Phone _____________________ Email _____________________________________________________________________________________ Emergency Contact ______________________________________________ Phone _____________________
Have you ever received a professional massage?
□ Yes
□ No
Are you currently taking any medications?
□ Yes
□ No
If yes, please list name and reason for medication(s): __________________________________________________________________________________ __________________________________________________________________________________ Are you currently pregnant?
□ Yes
□ No
Please review the list below and check those conditions that have affected your health either recently or in the past. □ □ □ □ □ □ □ □ □ □ □ □ □ □ □
Allergies/Sensitivities Arthritis Autoimmune condition Back problems Bone fractures/dislocations Bruise easily Cancer/related treatments Chemical dependency (alcohol, drug, tobacco) Chronic pain Constipation/Diarrhea Diabetes Digestive condition Epilepsy Headaches/Migraines Head/Neck Trauma
□ □ □ □ □ □ □ □ □ □ □ □ □
Heart condition High blood pressure Kidney disease Numbness/Tingling/Hypersensitivity Phlebitis/Varicose Veins Recent Surgery Scoliosis Skin Conditions/Lesions/Plantar Warts Sleep disorder Soft tissue sprains or strains Spinal disk injury/disease Thrombosis/Embolism TMJ disorder
Please list other conditions not mentioned above: ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________ Information and Suggestions 1. Prior to your massage, please remove contact lenses and all jewelry. Pull long hair back with a clip or band. 2. In general, massage is given while you are unclothed. However, you may choose to wear undergarments or a swimsuit. You will be covered with a top sheet throughout your session. This is your massage and you should be as comfortable as possible. 3. Feel free to ask your therapist questions before, during, and after the session. Your therapist is a highly trained professional and will be happy to make you feel informed and comfortable. 4. After your massage, you should hydrate your body by drinking water regularly.
Acknowledgement 1. I am at least 18 years of age and that the treatments provided at the Herbert Wellness Center are not intended as a diagnosis and do not replace medical treatment.
2. The information provided in this form is true, accurate and complete and that certain treatments may be refused to me on the basis of the information provided herein.
3. This is a therapeutic massage and any sexual remarks or advances will terminate the session and I will be liable for payment of the scheduled treatment.
4. Being that massage should not be done under certain medical conditions, I affirm that I have answered all questions pertaining to medical conditions truthfully.
5. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort.
6. 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.
7. I agree to give 24-hour notice for a scheduled session that I cannot keep. I am aware that I may be charged the full fee for any missed sessions or for sessions that I do not give 24-hour notice to cancel or reschedule.
Signed __________________________________________________________________ Date _____________________
If a minor, Signature of Guardian/Parent is required: _____________________________ Date _____________________
Disclaimer: The Herbert Wellness Center will not be held liable for any injury or condition that arises from application of massage despite completion of this form. The form is intended as an assessment tool only and serves as a guide for the application of massage. DO NOT WRITE BELOW THIS LINE. STAFF ONLY. ______________________________________________________________________________________________________________________________ _________ STAFF NOTES: