Vanilla Massage Therapy

MASSAGE INTAKE FORM

 

Gender First Name Last Name

Address

Home Phone Cell E-mail

Birth Date Martial Status: married single divorced widowed

Occupation

Emergency Contact Name Contact Phone

Referred By (how did you hear about me)

 

MASSAGE INFORMATION

First Professional Massage: yes no , How Frequently Do You Have Massage

 

MEDICAL INFORMATION

List Accidents/Injuries, hospitalizations and surgeries: when they occurred and treatment received

Any lingering effects from the above or do you feel you have recovered?

Chronic, ongoing pain? No Yes, please describe and any care or treatment you receive

Do activities effect the pain? No Yes, please describe

Are you currently being treated medically or taking prescribed drugs? No Yes, please describe

Please list all over the counter, supplements, and/or herbs taken and why

 

HISTORY (helps determine treatment options)

Musculoskeletal Digestive Nervous System
osteoporosis ulcers dizziness
arthritis colitis ALS
hypothyroidism IBS multiple sclerosis
fibromyalgia crone's disease parkinson's disease
chronic fatique gluten intolerance bell's palsy
gout in constipation neuritis
bursitis diarrhea spinal cord injury
plantar fascitis gallstones trigeminal neuralgia
cysts/lipomas gas/bloating seizures/epilepsy
TMJ chronic indigestion Other
chronic headaches Circulatory diabetes
tendonitis heart problems: pregnancy
whiplash stroke cancer
strains/sprains palpitations kidney disease
chronic pain in: mitral valve prolapse hepatitis
neck anemia HIV/AIDS
low-back hemophilia Lupus
mid-back hypertension Postoperative:
upper-back low blood pressure cystitis
hip peripheral artery disease high stress
arm raynaud's disease grieving
leg varicose veins anxiety/panic attacks
shoulder blood clots/phlebitis bipolar syndrome
wrist/hand Skin PMS/menopause difficulties
On computer more than 2hrs/day fungal infections poor sleep/insomnia
Respiratory athlete's foot allergies effecting:
pneumonia impetigo facial skin
asthma eczema/dermatitis body skin
breathing problems psoriasis nose/sinuses
sinusitis easily irritated skin eyes
other: other: stomach/gut
orthopedic pins or plates
other:

 

TERMS OF TREATMENT

The above information is accurate. I understand that Massage Therapists do not diagnose disease or prescribe drugs and that they are not a substitute for medical care. I agree to alert my practitioner of any physical/emotional changes as they occur. I also understand that a missed appointment might incur charges that I must pay.

By placing my initials, I confirm my agreement to the "Terms of Treatment": * (initials)

Signed ______________________________________________________________ Date:_________________
(Please submit this form and I will have you sign it when I arrive to your place)

You are all done! All you need to do now is press the "Submit" button below.