CONFIDENTIAL INTAKE FORM AND RECORD

*** Please print and bring with you to your first appointment, and take a few moments to read our policy statement.***

Rates:
30 minutes: $50
60 minutes: $80
90 minutes: $120

Payment by cash, check, VISA or MasterCard

MASSAGE THERAPIST_________________

Name: __________________________________________ Session Date______________________

Address: __________________________________________________________________________

City: ____________________________ State: _________________ Zip Code: _________________

Daytime Phone: ________________________ Evening Phone: ______________________________

Date of Birth: __________________Occupation: _________________________________________

Referred by: ______________________ E-mail Address: __________________________________

E-mail would be used for scheduling purposes and/or business updates; your e-mail address will remain confidential

Is this your first Professional Massage? _______ If no, how long ago was the last? ______________

Are you presently under a doctor or therapists care? _____________________________________

What medications are you taking? _____________________________________________________

Please list any recent injuries, surgeries, accidents: _____________________________________

______________________________________________________.

Please list any allergies: _____________________________________________________________

Are you pregnant? ______ If yes how many months? ______ Due Date? _______________________

Please list your reasons for seeking a massage? __________________________________________

Please check if you have experienced __disk problems/ herniations __scoliosis

The following: __diabetes __seizures

__aneurysm/ blood clots __edema/ swelling __shoulder pain/ problems

__arthritis __fibromyalgia/ chronic fatigue __sleep disturbances

__asthma __frequent headaches __stroke

__athlete’s foot __heart attack/disease __tendonitis

__recurring back pain __Hepatitis __tingling in extremities

__bone/ joint condition __high/low blood pressure __TMJ/ jaw tension

__infection __HIV infection __torn cartilage/ ligament

__bursitis __hypoglycemia __Tuberculosis

__cancer/ malignancies __knee pain/ problems __varicose veins

__chest pain/ tightness __Multiple Sclerosis __whiplash

__cold hands/ feet __muscle spasm(s) __any contagious disease

__constipation or diarrhea __paralysis __other: ______________

__clinical depression __sciatica _____________________

Please detail any checked areas: ____________________________________________________________

________________________________________________________________.

Please circle any specific areas you would like me to focus on: head face neck arms legs

abdomen back chest buttocks feet other____________________

Please circle any specific areas you would like me to avoid: head face neck arms legs

abdomen back chest buttocks feet other____________________

Is there any other information you feel would be helpful to share at this time? ____________________

________________________________________________________________________.