Massage by Marcel - Client Intake Form

E-mail Address: *
First Name: *
Last Name *
Address: *

State: *
Zip: *
Home Phone:
Cell Phone
Work Phone:
Occupation:

Date of Birth: *
How did you hear about me?
Referred by?
Have you ever received massage therapy? *
Yes No
If Yes, How Often?
What types of Massage have you experienced?	Swedish Deep Tissue Shiatsu Reflexology Other
What type of Massage are you seeking?
Swedish Relaxation Deep Tissue/Therapeutic Other
Do you have a pressure preference?	light pressure medium pressure deep pressure
Please let me know any particular areas of discomfort:
Are there any areas you especially dislike to be massaged? (ex. face, scalp, feet, etc.)
Are you currently taking any medications?	Yes No
If yes, Please list name & reason for medications:
Are you currently under care of a healthcare professional?	Yes No
If yes, please list names & reason for treatment:
Please check those conditions that have affected your health either recently or in the past.
arthritis diabetes blood clots broken/dislocated bones bruise easily cancer chronic pain constipation/diarrhea auto-immune condition (fibromyalgia, lupus, AIDS, etc.) hepatitis (A, B, C, other) circulation problems Bursitis recent injury/surgery TMJ disorder depression, panic disorder, other diverticulitis headaches heart conditions back problems high blood pressure low blood pressure insomnia muscle strain/sprain pregnancy scoliosis seizures whiplash skin conditions stroke Osteoporosis Varicose veins
If you need to add more detail to any of the above, or if there is anything else to share, please do so:
Do you have any of the following at this time?	skin rash/skin condition cold/flu open cuts severe pain anything contagious injuries/bruises
Do you have any allergies to:	medications foods (nuts, etc.) environmental allergens (dust, pollen, fragrances) reactions to skin care products
Please give details if any of the above are checked:
Do you wear:	contact lenses hearing aid hairpiece
What are your goals/expectations for your therapy session?
What qualities are you seeking in a therapist?
Please read the information, then initial the box. I understand that the massage/bodywork I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage or bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session should be construed as such. Because massage/bodywork cannot be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and that I have answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner�s part should I forget to do so. It is also understood that any elicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. *

Today's Date: *