Massage Intake, Policies & Consent Agreement
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Personal Info
First Name
Last Name
Date of Birth (MM/DD/YYYY)
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Contact Info
Mobile Phone
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Source of Referral
Address
City
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Australia
Canada
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Algeria
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Anguilla
Antarctica
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Bolivia, Plurinational State Of
Bosnia And Herzegovina
Botswana
Bouvet Island
Brazil
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Bulgaria
Burkina Faso
Burundi
C?te D'Ivoire
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
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Congo, The Democratic Republic Of The
Cook Islands
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
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Dominican Republic
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Egypt
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Equatorial Guinea
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Estonia
Ethiopia
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Faroe Islands
Fiji
Finland
France
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Gabon
Gambia
Georgia
Germany
Ghana
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Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island And Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Isle Of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
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Kenya
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Korea, Democratic People'S Republic Of
Korea, Republic Of
Kosovo
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Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, The Former Yugoslav Republic Of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States Of
Moldova, Republic Of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Barth?lemy
Saint Helena, Ascension And Tristan Da Cunha
Saint Kitts And Nevis
Saint Lucia
Saint Martin
Saint Pierre And Miquelon
Saint Vincent And The Grenadines
Samoa
San Marino
Sao Tome And Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia And The South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard And Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province Of China
Tajikistan
Tanzania, United Republic Of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks And Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela, Bolivarian Republic Of
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis And Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Province / State
Postal / Zip Code
Emergency Contact
Emergency Contact
Emergency Phone
Relationship
Doctor
Doctor's Name
Doctor's Phone
Doctor's Address
Other
Height & Weight
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Other
What is your dominant hand?
Right handed
Left handed
Ambidextrous
Primary Concerns & Health Background
Primary Complaint or Reason for Massage
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Describe how and when the pain started
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Describe the Pain (ex. Aching, Cramping, Sharp, Shooting, Numbness, Tingling, Stabbing, Tender, Tightness, Tension, etc.)
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What makes it better?
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What makes it worse?
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Current Treatment/Remedies
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Past Treatments
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Date of last massage
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On a scale of 1-10, what is your pain right now?
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What kind of pressure do you prefer?
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Occupational Activities
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Recreational Activities
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Massage Goals
Relaxation
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Improve Range of Motion
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Pain Relief
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Tension Relief
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To Start a Regular Massage Plan
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Therapeutic Massage
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Conditions
Area of Complaint
Neck
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Upper Back
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Mid Back
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Low Back
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Chest
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Abdomen
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Left Arm
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Right Arm
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Left Shoulder
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Right Shoulder
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Left Elbow
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Right Elbow
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Left Wrist
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Right Wrist
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Left Hand
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Right Hand
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Left Leg
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Right Leg
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Left Hip
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Right Hip
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Left Knee
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Right Knee
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Left Ankle
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Right Ankle
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Left Foot
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Right Foot
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Other, please specify:
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Circulatory
Blood Clots
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Heart Disease
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Aneurysm
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Congestive Heart Failure
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Phlebitis
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Varicose Veins
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Heart Attack
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Blood Pressure
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Lymphedema
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Thrombosis/Embolism
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Swelling
High Blood Pressure
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Low Blood Pressure
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Cold Hands
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Cold Feet
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Other, or anything not listed
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Digestive
Constipation
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Irritable Bowel Syndrome
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Low Blood Sugar/Hypoglycemia
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Diabetes
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Crohn's Disease
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Diverticulitis
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Ulcerative Colitis
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Other, or anything not listed
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Headaches
Migraines
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Headaches
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Sinus
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Chronic Daily Headache
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Tension
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Other, or anything not listed
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Nervous System
Sciatica
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Multiple Sclerosis
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Stroke
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Epilepsy
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Seisure
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Fainting
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Seizure Disorder
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Vertebral and Spinal Cord Injury
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Cerebral Palsy
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Dizziness
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Other, or anything not listed
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Musculoskeletal
Muscle Pain
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Muscle Weakness
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Strain/Sprain
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Joint Issue
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Foot Issue
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Broken Bones
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Neck Injury
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Osteoporosis
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Tendonitis
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Arthritis
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Herniated or Bulging Disc (Where and what stage?)
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Ankylosing Spondylitis
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Coccyx Injury
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Scoliosis
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Spondylolisthesis
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Stenosis
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Degenerative Disc Disease
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Laminectomy
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Spinal Rod
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Fusion
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Screws
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Artificial Joints / Special Equipment
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Dislocation
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Tendonitis/Bursitis
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Fracture
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Other, or anything not listed
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Respiratory
Respiratory Conditions
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Sinus Congestion
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Asthma
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Other, or anything not listed
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Skin Issues
Athlete's Foot
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Dry Skin
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Burn
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Non-Surgical Scars
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Sensitive Skin
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Skin Irritations
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Herpes
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Psoriasis
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Cellulitis
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Rash
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Bruise Easily
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Contagious Disease
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Skin Irritations
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Plantar's Wart
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Other, or anything not listed
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Reproductive
Pregnancy (*Barefoot Massage will not be performed if you are pregnant or trying to conceive)
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Trying to Conceive
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Number of Previous Pregnancies/Births
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Previous C-Section
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Nursing
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Premenstrual Syndrome
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Other, or anything not listed
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TMJ (Jaw)
Ear Stuffiness
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Ear Blockage
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Ear Pressure
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Jaw Pain
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Locking
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Clenching
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Grinding
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Difficulty Opening Jaw
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Clicking
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Difficulty Chewing
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Other, or anything not listed
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Other
Do you have any allergies? If yes, please Explain
I wear Contact Lenses
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Cancer
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Are you a Smoker?
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Augmentation/Implants: breast, gluteal, cheeks, lips, calves, etc.
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Menopause
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Abdominal Hernia
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Eye/Optical Issue
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Recent Lasik Surgery (past 72 hours)
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Insomnia
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Injections or Shots
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Amputation
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Depression
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Claustrophobia
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PTSD
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Other Medical Conditions
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Other Diagnosed Diseases
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Other (anything not listed)
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Medications
Medications, Vitamins/Herbs (include reason for taking)
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Significant Injuries
Significant INJURIES during lifetime (give year)
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Surgeries
Do you have any upcoming medical procedures? If yes, please Explain
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All SURGERIES (give year)
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Have you had surgery within the last 6 WEEKS (Please provide a note from your Doctor allowing you to receive massage)
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