Intake Form Personal InformationDate Of Visit MM slash DD slash YYYY Name First name Last name BirthdayGenderEmail PhoneOccupationReferred byAddressCityStateZip codePhysician namePhysician PhoneEmergency contactEmergency phoneReason for Visit How would you rate your general health? Poor Fair Good Excellent Have you ever had a professional massage? No Yes Last Time? Describe injuries, concerns, or issues to address + causes and dates of occurrencesDescribe any treatment you've received for these particular issuesDescribe your treatment goalsHealth History Cardiovascular Congestive heart failure Heart disease Low blood pressure Poor circulation Varicose veins Embolism Hemophilia Pacemaker O Stroke Family history Heart attack High blood pressure Phlebitis Thrombosis Head & Neck Dizziness Ear problems Headaches Hearing loss Jaw pain (TMJ) Migraines Vision loss Vision problems Musculoskeletal Arthritis Osteoporosis Artificial joint Surgical pin/wire Bursitis Tendonitis Neurological Epilepsy Sensory loss/change Multiple sclerosis Sciatica Numbness/tingling Seizures Respiratory Asthma Emphysema Smoker Bronchitis Shortness of breath Tuberculosis Chronic cough Sinusitis Family history Reproductive Given birth Gynecological problems Pregnant Skin Bruise easily Skin irritations Skin conditions Skin infections Miscellaneous Anxiety Cancer Depression Diabetes HIV/AIDS Digestive conditions Fibromyalgia Stress Others Waiver Please read and sign: I understand that massage therapy is provided for stress reduction, relaxation, relief from muscular tension, and improvement of circulation and energy flow. If I experience pain or discomfort during the session, I will immediately inform my therapist so that pressure/strokes can be adjusted to my level of comfort. I will not hold my therapist responsible for any pain or discomfort I experience during or after the session. I understand that today's services are not a substitute for medical care and that my therapist is not qualified to diagnose, prescribe, or treat physical/mental illness. I affirm that I have notified my therapist of all known medical conditions and injuries. I agree to inform the therapist of any changes in my health and medical condition and that there shall be no liability on the therapist's part should I forget to do so. I understand that massage is entirely therapeutic and non-sexual in nature. By signing this release, I waive and release my therapist from any liability, past, present, and future, relating to massage therapy and bodywork. SignatureDate MM slash DD slash YYYY
