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Massage Client Intake Form

Please read and sign that you understand and agree with the following policies:

CANCELLATION & LATE ARRIVALS

If you need to change your appointment, please let us know at least 3 hours in advance for individual bookings or 48 hours for spa parties of 2 or more. Missed appointments or cancellations without adequate notice will incur a fee: $40 for the first missed appointment, and the full service amount for subsequent no-shows. If you arrive late, we may still be able to accommodate you if there’s availability; however, your appointment time may be shortened accordingly.


CLIENT AGREEMENT

I understand that my massage is intended for relaxation and relief of muscle tension. I will inform my therapist if I experience any discomfort so adjustments can be made. I acknowledge that massage therapists do not diagnose or treat medical conditions and that I should consult a physician for any health concerns. I understand that any inappropriate behavior or any sexually suggestive remarks will end the session immediately, and I will still be responsible for payment.

I acknowledge that the massage therapists are independent contractors, not employees of Sage Wellness Spa. Therefore, liability, if any, that may arise from the massage service is limited as provided by law. I certify that I am the individual receiving this service or authorized to consent for the recipient.


RELEASE OF MASSAGE RECORDS

I authorize Sage Wellness Spa to release my massage records, including intake forms, treatment notes, and receipts, to my attorneys, healthcare providers, or insurance case managers as needed for claims processing.


GRATUITY

Gratuity is an important part of our therapists' and estheticians' income. Customary tips range from $15 to $50, based on the service quality and duration. We keep our service fees affordable, so you can tip your therapist or esthetician comfortably based on the quality of your experience.

Today's Date: December 21, 2024

 

First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
First Client's Information

How did you hear about us?

Who can we thank for referring you? Please enter first and last name of the client that referred you.

MASSAGE PREFERENCES

Have you had a professional massage before?*
No
Yes

If yes, what types of massage have you had (swedish,deep tissue, hot stone, etc)?

Frequency of massages?
What are your goals for treatment?
Relaxation
Pain Relief
Stress Reduction
What type of pressure do you prefer?
Light
Medium
Deep

CURRENT HEALTH


Reason for initial visit
How would you describe your current stress level?
Low
Medium
High
Very High
Do you exercise regularly and/or participate in any sports?*
No
Yes

If yes, what kind of exercise/sports?
Do you perform any repetitive movement in your work, sports or hobby?*
No
Yes

If yes, describe
Do you sit for long hours at a workstation, computer or driving?*
No
Yes

If yes, describe
Are you experiencing tension, stiffness, discomfort or pain?*
No
Yes

If yes, describe

Please list any major and/or recent injuries, surgeries, or areas of inflammation.

List any medications you are currently taking:
Do you have sensitive skin?*
No
Yes
Do you have any allergies to oils, lotions, ointments?*
No
Yes

If yes, please explain

List any known allergies

DO YOU HAVE ANY OF THE FOLLOWING CONDITIONS? CHECK ALL THAT APPLY.

MUSCULOSKELETAL
Arthritis/Gout
Bone or joint disease
Disk Problems
Jaw Pain (TMJ)
Lupus
Migraines/Headaches
Osteoporosis
Scoliosis
Spinal Problems
Tendonitis/Bursitis
CIRCULATORY
Heart Condition
Phlebitis/Varicose Veins
Blood Clots
High/Low Blood Pressure
Lymphedema
Thrombosis/Embolism
RESPIRATORY
Breathing Difficulty/Asthma
Emphysema
Sinus Problems
Allergies, specify:
NERVOUS SYSTEM
Chronic Pain
Multiple Sclerosis
Numbness/Tingling
Paralysis
Parkinson's Disease
Pinched Nerve
Seizures/Epilepsy
Shingles
SKIN
Athlete's Foot
Cosmetic Surgery
Herpes/Cold Sores
Rashes
Allergies, specify:
DIGESTIVE
Bladder/Kidney Ailment
Colitis
Crohn's Disease
Irritable Bowel Syndrome
Ulcers
PSYCHOLOGICAL
Anxiety/Stress/ptsd
Depression
Fatigue/Sleep Disorder
OTHER
Cancer/Tumors
Diabetes
Drug/Alcohol/Tobacco Use
Contact Lenses
Dentures
Hearing Aids
Broken/Fractured Bones
Bruise easily
Fibromyalgia
Flu/cold symptoms in the last 24 hours
Infectious Disease
Spasms/Cramps
Stroke
Sprains/Strains

Any other medical condition(s) not listed:

Please explain any of the conditions that you have marked above:
Are you pregnant?*
No
Yes

If yes, how many weeks?

Client Agreement

It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my Practitioner of any changes in my health status. 

First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Second Client's Information

How did you hear about us?

Who can we thank for referring you? Please enter first and last name of the client that referred you.

MASSAGE PREFERENCES

Have you had a professional massage before?*
No
Yes

If yes, what types of massage have you had (swedish,deep tissue, hot stone, etc)?

Frequency of massages?
What are your goals for treatment?
Relaxation
Pain Relief
Stress Reduction
What type of pressure do you prefer?
Light
Medium
Deep

CURRENT HEALTH


Reason for initial visit
How would you describe your current stress level?
Low
Medium
High
Very High
Do you exercise regularly and/or participate in any sports?*
No
Yes

If yes, what kind of exercise/sports?
Do you perform any repetitive movement in your work, sports or hobby?*
No
Yes

If yes, describe
Do you sit for long hours at a workstation, computer or driving?*
No
Yes

If yes, describe
Are you experiencing tension, stiffness, discomfort or pain?*
No
Yes

If yes, describe

Please list any major and/or recent injuries, surgeries, or areas of inflammation.

List any medications you are currently taking:
Do you have sensitive skin?*
No
Yes
Do you have any allergies to oils, lotions, ointments?*
No
Yes

If yes, please explain

List any known allergies

DO YOU HAVE ANY OF THE FOLLOWING CONDITIONS? CHECK ALL THAT APPLY.

MUSCULOSKELETAL
Arthritis/Gout
Bone or joint disease
Disk Problems
Jaw Pain (TMJ)
Lupus
Migraines/Headaches
Osteoporosis
Scoliosis
Spinal Problems
Tendonitis/Bursitis
CIRCULATORY
Heart Condition
Phlebitis/Varicose Veins
Blood Clots
High/Low Blood Pressure
Lymphedema
Thrombosis/Embolism
RESPIRATORY
Breathing Difficulty/Asthma
Emphysema
Sinus Problems
Allergies, specify:
NERVOUS SYSTEM
Chronic Pain
Multiple Sclerosis
Numbness/Tingling
Paralysis
Parkinson's Disease
Pinched Nerve
Seizures/Epilepsy
Shingles
SKIN
Athlete's Foot
Cosmetic Surgery
Herpes/Cold Sores
Rashes
Allergies, specify:
DIGESTIVE
Bladder/Kidney Ailment
Colitis
Crohn's Disease
Irritable Bowel Syndrome
Ulcers
PSYCHOLOGICAL
Anxiety/Stress/ptsd
Depression
Fatigue/Sleep Disorder
OTHER
Cancer/Tumors
Diabetes
Drug/Alcohol/Tobacco Use
Contact Lenses
Dentures
Hearing Aids
Broken/Fractured Bones
Bruise easily
Fibromyalgia
Flu/cold symptoms in the last 24 hours
Infectious Disease
Spasms/Cramps
Stroke
Sprains/Strains

Any other medical condition(s) not listed:

Please explain any of the conditions that you have marked above:
Are you pregnant?*
No
Yes

If yes, how many weeks?

Client Agreement

It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my Practitioner of any changes in my health status. 

Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Third Client's Information

How did you hear about us?

Who can we thank for referring you? Please enter first and last name of the client that referred you.

MASSAGE PREFERENCES

Have you had a professional massage before?*
No
Yes

If yes, what types of massage have you had (swedish,deep tissue, hot stone, etc)?

Frequency of massages?
What are your goals for treatment?
Relaxation
Pain Relief
Stress Reduction
What type of pressure do you prefer?
Light
Medium
Deep

CURRENT HEALTH


Reason for initial visit
How would you describe your current stress level?
Low
Medium
High
Very High
Do you exercise regularly and/or participate in any sports?*
No
Yes

If yes, what kind of exercise/sports?
Do you perform any repetitive movement in your work, sports or hobby?*
No
Yes

If yes, describe
Do you sit for long hours at a workstation, computer or driving?*
No
Yes

If yes, describe
Are you experiencing tension, stiffness, discomfort or pain?*
No
Yes

If yes, describe

Please list any major and/or recent injuries, surgeries, or areas of inflammation.

List any medications you are currently taking:
Do you have sensitive skin?*
No
Yes
Do you have any allergies to oils, lotions, ointments?*
No
Yes

If yes, please explain

List any known allergies

DO YOU HAVE ANY OF THE FOLLOWING CONDITIONS? CHECK ALL THAT APPLY.

MUSCULOSKELETAL
Arthritis/Gout
Bone or joint disease
Disk Problems
Jaw Pain (TMJ)
Lupus
Migraines/Headaches
Osteoporosis
Scoliosis
Spinal Problems
Tendonitis/Bursitis
CIRCULATORY
Heart Condition
Phlebitis/Varicose Veins
Blood Clots
High/Low Blood Pressure
Lymphedema
Thrombosis/Embolism
RESPIRATORY
Breathing Difficulty/Asthma
Emphysema
Sinus Problems
Allergies, specify:
NERVOUS SYSTEM
Chronic Pain
Multiple Sclerosis
Numbness/Tingling
Paralysis
Parkinson's Disease
Pinched Nerve
Seizures/Epilepsy
Shingles
SKIN
Athlete's Foot
Cosmetic Surgery
Herpes/Cold Sores
Rashes
Allergies, specify:
DIGESTIVE
Bladder/Kidney Ailment
Colitis
Crohn's Disease
Irritable Bowel Syndrome
Ulcers
PSYCHOLOGICAL
Anxiety/Stress/ptsd
Depression
Fatigue/Sleep Disorder
OTHER
Cancer/Tumors
Diabetes
Drug/Alcohol/Tobacco Use
Contact Lenses
Dentures
Hearing Aids
Broken/Fractured Bones
Bruise easily
Fibromyalgia
Flu/cold symptoms in the last 24 hours
Infectious Disease
Spasms/Cramps
Stroke
Sprains/Strains

Any other medical condition(s) not listed:

Please explain any of the conditions that you have marked above:
Are you pregnant?*
No
Yes

If yes, how many weeks?

Client Agreement

It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my Practitioner of any changes in my health status. 

Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Information

How did you hear about us?

Who can we thank for referring you? Please enter first and last name of the client that referred you.

MASSAGE PREFERENCES

Have you had a professional massage before?*
No
Yes

If yes, what types of massage have you had (swedish,deep tissue, hot stone, etc)?

Frequency of massages?
What are your goals for treatment?
Relaxation
Pain Relief
Stress Reduction
What type of pressure do you prefer?
Light
Medium
Deep

CURRENT HEALTH


Reason for initial visit
How would you describe your current stress level?
Low
Medium
High
Very High
Do you exercise regularly and/or participate in any sports?*
No
Yes

If yes, what kind of exercise/sports?
Do you perform any repetitive movement in your work, sports or hobby?*
No
Yes

If yes, describe
Do you sit for long hours at a workstation, computer or driving?*
No
Yes

If yes, describe
Are you experiencing tension, stiffness, discomfort or pain?*
No
Yes

If yes, describe

Please list any major and/or recent injuries, surgeries, or areas of inflammation.

List any medications you are currently taking:
Do you have sensitive skin?*
No
Yes
Do you have any allergies to oils, lotions, ointments?*
No
Yes

If yes, please explain

List any known allergies

DO YOU HAVE ANY OF THE FOLLOWING CONDITIONS? CHECK ALL THAT APPLY.

MUSCULOSKELETAL
Arthritis/Gout
Bone or joint disease
Disk Problems
Jaw Pain (TMJ)
Lupus
Migraines/Headaches
Osteoporosis
Scoliosis
Spinal Problems
Tendonitis/Bursitis
CIRCULATORY
Heart Condition
Phlebitis/Varicose Veins
Blood Clots
High/Low Blood Pressure
Lymphedema
Thrombosis/Embolism
RESPIRATORY
Breathing Difficulty/Asthma
Emphysema
Sinus Problems
Allergies, specify:
NERVOUS SYSTEM
Chronic Pain
Multiple Sclerosis
Numbness/Tingling
Paralysis
Parkinson's Disease
Pinched Nerve
Seizures/Epilepsy
Shingles
SKIN
Athlete's Foot
Cosmetic Surgery
Herpes/Cold Sores
Rashes
Allergies, specify:
DIGESTIVE
Bladder/Kidney Ailment
Colitis
Crohn's Disease
Irritable Bowel Syndrome
Ulcers
PSYCHOLOGICAL
Anxiety/Stress/ptsd
Depression
Fatigue/Sleep Disorder
OTHER
Cancer/Tumors
Diabetes
Drug/Alcohol/Tobacco Use
Contact Lenses
Dentures
Hearing Aids
Broken/Fractured Bones
Bruise easily
Fibromyalgia
Flu/cold symptoms in the last 24 hours
Infectious Disease
Spasms/Cramps
Stroke
Sprains/Strains

Any other medical condition(s) not listed:

Please explain any of the conditions that you have marked above:
Are you pregnant?*
No
Yes

If yes, how many weeks?

Client Agreement

It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my Practitioner of any changes in my health status. 

Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Information

How did you hear about us?

Who can we thank for referring you? Please enter first and last name of the client that referred you.

MASSAGE PREFERENCES

Have you had a professional massage before?*
No
Yes

If yes, what types of massage have you had (swedish,deep tissue, hot stone, etc)?

Frequency of massages?
What are your goals for treatment?
Relaxation
Pain Relief
Stress Reduction
What type of pressure do you prefer?
Light
Medium
Deep

CURRENT HEALTH


Reason for initial visit
How would you describe your current stress level?
Low
Medium
High
Very High
Do you exercise regularly and/or participate in any sports?*
No
Yes

If yes, what kind of exercise/sports?
Do you perform any repetitive movement in your work, sports or hobby?*
No
Yes

If yes, describe
Do you sit for long hours at a workstation, computer or driving?*
No
Yes

If yes, describe
Are you experiencing tension, stiffness, discomfort or pain?*
No
Yes

If yes, describe

Please list any major and/or recent injuries, surgeries, or areas of inflammation.

List any medications you are currently taking:
Do you have sensitive skin?*
No
Yes
Do you have any allergies to oils, lotions, ointments?*
No
Yes

If yes, please explain

List any known allergies

DO YOU HAVE ANY OF THE FOLLOWING CONDITIONS? CHECK ALL THAT APPLY.

MUSCULOSKELETAL
Arthritis/Gout
Bone or joint disease
Disk Problems
Jaw Pain (TMJ)
Lupus
Migraines/Headaches
Osteoporosis
Scoliosis
Spinal Problems
Tendonitis/Bursitis
CIRCULATORY
Heart Condition
Phlebitis/Varicose Veins
Blood Clots
High/Low Blood Pressure
Lymphedema
Thrombosis/Embolism
RESPIRATORY
Breathing Difficulty/Asthma
Emphysema
Sinus Problems
Allergies, specify:
NERVOUS SYSTEM
Chronic Pain
Multiple Sclerosis
Numbness/Tingling
Paralysis
Parkinson's Disease
Pinched Nerve
Seizures/Epilepsy
Shingles
SKIN
Athlete's Foot
Cosmetic Surgery
Herpes/Cold Sores
Rashes
Allergies, specify:
DIGESTIVE
Bladder/Kidney Ailment
Colitis
Crohn's Disease
Irritable Bowel Syndrome
Ulcers
PSYCHOLOGICAL
Anxiety/Stress/ptsd
Depression
Fatigue/Sleep Disorder
OTHER
Cancer/Tumors
Diabetes
Drug/Alcohol/Tobacco Use
Contact Lenses
Dentures
Hearing Aids
Broken/Fractured Bones
Bruise easily
Fibromyalgia
Flu/cold symptoms in the last 24 hours
Infectious Disease
Spasms/Cramps
Stroke
Sprains/Strains

Any other medical condition(s) not listed:

Please explain any of the conditions that you have marked above:
Are you pregnant?*
No
Yes

If yes, how many weeks?

Client Agreement

It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my Practitioner of any changes in my health status. 

Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Information

How did you hear about us?

Who can we thank for referring you? Please enter first and last name of the client that referred you.

MASSAGE PREFERENCES

Have you had a professional massage before?*
No
Yes

If yes, what types of massage have you had (swedish,deep tissue, hot stone, etc)?

Frequency of massages?
What are your goals for treatment?
Relaxation
Pain Relief
Stress Reduction
What type of pressure do you prefer?
Light
Medium
Deep

CURRENT HEALTH


Reason for initial visit
How would you describe your current stress level?
Low
Medium
High
Very High
Do you exercise regularly and/or participate in any sports?*
No
Yes

If yes, what kind of exercise/sports?
Do you perform any repetitive movement in your work, sports or hobby?*
No
Yes

If yes, describe
Do you sit for long hours at a workstation, computer or driving?*
No
Yes

If yes, describe
Are you experiencing tension, stiffness, discomfort or pain?*
No
Yes

If yes, describe

Please list any major and/or recent injuries, surgeries, or areas of inflammation.

List any medications you are currently taking:
Do you have sensitive skin?*
No
Yes
Do you have any allergies to oils, lotions, ointments?*
No
Yes

If yes, please explain

List any known allergies

DO YOU HAVE ANY OF THE FOLLOWING CONDITIONS? CHECK ALL THAT APPLY.

MUSCULOSKELETAL
Arthritis/Gout
Bone or joint disease
Disk Problems
Jaw Pain (TMJ)
Lupus
Migraines/Headaches
Osteoporosis
Scoliosis
Spinal Problems
Tendonitis/Bursitis
CIRCULATORY
Heart Condition
Phlebitis/Varicose Veins
Blood Clots
High/Low Blood Pressure
Lymphedema
Thrombosis/Embolism
RESPIRATORY
Breathing Difficulty/Asthma
Emphysema
Sinus Problems
Allergies, specify:
NERVOUS SYSTEM
Chronic Pain
Multiple Sclerosis
Numbness/Tingling
Paralysis
Parkinson's Disease
Pinched Nerve
Seizures/Epilepsy
Shingles
SKIN
Athlete's Foot
Cosmetic Surgery
Herpes/Cold Sores
Rashes
Allergies, specify:
DIGESTIVE
Bladder/Kidney Ailment
Colitis
Crohn's Disease
Irritable Bowel Syndrome
Ulcers
PSYCHOLOGICAL
Anxiety/Stress/ptsd
Depression
Fatigue/Sleep Disorder
OTHER
Cancer/Tumors
Diabetes
Drug/Alcohol/Tobacco Use
Contact Lenses
Dentures
Hearing Aids
Broken/Fractured Bones
Bruise easily
Fibromyalgia
Flu/cold symptoms in the last 24 hours
Infectious Disease
Spasms/Cramps
Stroke
Sprains/Strains

Any other medical condition(s) not listed:

Please explain any of the conditions that you have marked above:
Are you pregnant?*
No
Yes

If yes, how many weeks?

Client Agreement

It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my Practitioner of any changes in my health status. 

Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Information

How did you hear about us?

Who can we thank for referring you? Please enter first and last name of the client that referred you.

MASSAGE PREFERENCES

Have you had a professional massage before?*
No
Yes

If yes, what types of massage have you had (swedish,deep tissue, hot stone, etc)?

Frequency of massages?
What are your goals for treatment?
Relaxation
Pain Relief
Stress Reduction
What type of pressure do you prefer?
Light
Medium
Deep

CURRENT HEALTH


Reason for initial visit
How would you describe your current stress level?
Low
Medium
High
Very High
Do you exercise regularly and/or participate in any sports?*
No
Yes

If yes, what kind of exercise/sports?
Do you perform any repetitive movement in your work, sports or hobby?*
No
Yes

If yes, describe
Do you sit for long hours at a workstation, computer or driving?*
No
Yes

If yes, describe
Are you experiencing tension, stiffness, discomfort or pain?*
No
Yes

If yes, describe

Please list any major and/or recent injuries, surgeries, or areas of inflammation.

List any medications you are currently taking:
Do you have sensitive skin?*
No
Yes
Do you have any allergies to oils, lotions, ointments?*
No
Yes

If yes, please explain

List any known allergies

DO YOU HAVE ANY OF THE FOLLOWING CONDITIONS? CHECK ALL THAT APPLY.

MUSCULOSKELETAL
Arthritis/Gout
Bone or joint disease
Disk Problems
Jaw Pain (TMJ)
Lupus
Migraines/Headaches
Osteoporosis
Scoliosis
Spinal Problems
Tendonitis/Bursitis
CIRCULATORY
Heart Condition
Phlebitis/Varicose Veins
Blood Clots
High/Low Blood Pressure
Lymphedema
Thrombosis/Embolism
RESPIRATORY
Breathing Difficulty/Asthma
Emphysema
Sinus Problems
Allergies, specify:
NERVOUS SYSTEM
Chronic Pain
Multiple Sclerosis
Numbness/Tingling
Paralysis
Parkinson's Disease
Pinched Nerve
Seizures/Epilepsy
Shingles
SKIN
Athlete's Foot
Cosmetic Surgery
Herpes/Cold Sores
Rashes
Allergies, specify:
DIGESTIVE
Bladder/Kidney Ailment
Colitis
Crohn's Disease
Irritable Bowel Syndrome
Ulcers
PSYCHOLOGICAL
Anxiety/Stress/ptsd
Depression
Fatigue/Sleep Disorder
OTHER
Cancer/Tumors
Diabetes
Drug/Alcohol/Tobacco Use
Contact Lenses
Dentures
Hearing Aids
Broken/Fractured Bones
Bruise easily
Fibromyalgia
Flu/cold symptoms in the last 24 hours
Infectious Disease
Spasms/Cramps
Stroke
Sprains/Strains

Any other medical condition(s) not listed:

Please explain any of the conditions that you have marked above:
Are you pregnant?*
No
Yes

If yes, how many weeks?

Client Agreement

It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my Practitioner of any changes in my health status. 

Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Information

How did you hear about us?

Who can we thank for referring you? Please enter first and last name of the client that referred you.

MASSAGE PREFERENCES

Have you had a professional massage before?*
No
Yes

If yes, what types of massage have you had (swedish,deep tissue, hot stone, etc)?

Frequency of massages?
What are your goals for treatment?
Relaxation
Pain Relief
Stress Reduction
What type of pressure do you prefer?
Light
Medium
Deep

CURRENT HEALTH


Reason for initial visit
How would you describe your current stress level?
Low
Medium
High
Very High
Do you exercise regularly and/or participate in any sports?*
No
Yes

If yes, what kind of exercise/sports?
Do you perform any repetitive movement in your work, sports or hobby?*
No
Yes

If yes, describe
Do you sit for long hours at a workstation, computer or driving?*
No
Yes

If yes, describe
Are you experiencing tension, stiffness, discomfort or pain?*
No
Yes

If yes, describe

Please list any major and/or recent injuries, surgeries, or areas of inflammation.

List any medications you are currently taking:
Do you have sensitive skin?*
No
Yes
Do you have any allergies to oils, lotions, ointments?*
No
Yes

If yes, please explain

List any known allergies

DO YOU HAVE ANY OF THE FOLLOWING CONDITIONS? CHECK ALL THAT APPLY.

MUSCULOSKELETAL
Arthritis/Gout
Bone or joint disease
Disk Problems
Jaw Pain (TMJ)
Lupus
Migraines/Headaches
Osteoporosis
Scoliosis
Spinal Problems
Tendonitis/Bursitis
CIRCULATORY
Heart Condition
Phlebitis/Varicose Veins
Blood Clots
High/Low Blood Pressure
Lymphedema
Thrombosis/Embolism
RESPIRATORY
Breathing Difficulty/Asthma
Emphysema
Sinus Problems
Allergies, specify:
NERVOUS SYSTEM
Chronic Pain
Multiple Sclerosis
Numbness/Tingling
Paralysis
Parkinson's Disease
Pinched Nerve
Seizures/Epilepsy
Shingles
SKIN
Athlete's Foot
Cosmetic Surgery
Herpes/Cold Sores
Rashes
Allergies, specify:
DIGESTIVE
Bladder/Kidney Ailment
Colitis
Crohn's Disease
Irritable Bowel Syndrome
Ulcers
PSYCHOLOGICAL
Anxiety/Stress/ptsd
Depression
Fatigue/Sleep Disorder
OTHER
Cancer/Tumors
Diabetes
Drug/Alcohol/Tobacco Use
Contact Lenses
Dentures
Hearing Aids
Broken/Fractured Bones
Bruise easily
Fibromyalgia
Flu/cold symptoms in the last 24 hours
Infectious Disease
Spasms/Cramps
Stroke
Sprains/Strains

Any other medical condition(s) not listed:

Please explain any of the conditions that you have marked above:
Are you pregnant?*
No
Yes

If yes, how many weeks?

Client Agreement

It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my Practitioner of any changes in my health status. 

Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Information

How did you hear about us?

Who can we thank for referring you? Please enter first and last name of the client that referred you.

MASSAGE PREFERENCES

Have you had a professional massage before?*
No
Yes

If yes, what types of massage have you had (swedish,deep tissue, hot stone, etc)?

Frequency of massages?
What are your goals for treatment?
Relaxation
Pain Relief
Stress Reduction
What type of pressure do you prefer?
Light
Medium
Deep

CURRENT HEALTH


Reason for initial visit
How would you describe your current stress level?
Low
Medium
High
Very High
Do you exercise regularly and/or participate in any sports?*
No
Yes

If yes, what kind of exercise/sports?
Do you perform any repetitive movement in your work, sports or hobby?*
No
Yes

If yes, describe
Do you sit for long hours at a workstation, computer or driving?*
No
Yes

If yes, describe
Are you experiencing tension, stiffness, discomfort or pain?*
No
Yes

If yes, describe

Please list any major and/or recent injuries, surgeries, or areas of inflammation.

List any medications you are currently taking:
Do you have sensitive skin?*
No
Yes
Do you have any allergies to oils, lotions, ointments?*
No
Yes

If yes, please explain

List any known allergies

DO YOU HAVE ANY OF THE FOLLOWING CONDITIONS? CHECK ALL THAT APPLY.

MUSCULOSKELETAL
Arthritis/Gout
Bone or joint disease
Disk Problems
Jaw Pain (TMJ)
Lupus
Migraines/Headaches
Osteoporosis
Scoliosis
Spinal Problems
Tendonitis/Bursitis
CIRCULATORY
Heart Condition
Phlebitis/Varicose Veins
Blood Clots
High/Low Blood Pressure
Lymphedema
Thrombosis/Embolism
RESPIRATORY
Breathing Difficulty/Asthma
Emphysema
Sinus Problems
Allergies, specify:
NERVOUS SYSTEM
Chronic Pain
Multiple Sclerosis
Numbness/Tingling
Paralysis
Parkinson's Disease
Pinched Nerve
Seizures/Epilepsy
Shingles
SKIN
Athlete's Foot
Cosmetic Surgery
Herpes/Cold Sores
Rashes
Allergies, specify:
DIGESTIVE
Bladder/Kidney Ailment
Colitis
Crohn's Disease
Irritable Bowel Syndrome
Ulcers
PSYCHOLOGICAL
Anxiety/Stress/ptsd
Depression
Fatigue/Sleep Disorder
OTHER
Cancer/Tumors
Diabetes
Drug/Alcohol/Tobacco Use
Contact Lenses
Dentures
Hearing Aids
Broken/Fractured Bones
Bruise easily
Fibromyalgia
Flu/cold symptoms in the last 24 hours
Infectious Disease
Spasms/Cramps
Stroke
Sprains/Strains

Any other medical condition(s) not listed:

Please explain any of the conditions that you have marked above:
Are you pregnant?*
No
Yes

If yes, how many weeks?

Client Agreement

It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my Practitioner of any changes in my health status. 

Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Information

How did you hear about us?

Who can we thank for referring you? Please enter first and last name of the client that referred you.

MASSAGE PREFERENCES

Have you had a professional massage before?*
No
Yes

If yes, what types of massage have you had (swedish,deep tissue, hot stone, etc)?

Frequency of massages?
What are your goals for treatment?
Relaxation
Pain Relief
Stress Reduction
What type of pressure do you prefer?
Light
Medium
Deep

CURRENT HEALTH


Reason for initial visit
How would you describe your current stress level?
Low
Medium
High
Very High
Do you exercise regularly and/or participate in any sports?*
No
Yes

If yes, what kind of exercise/sports?
Do you perform any repetitive movement in your work, sports or hobby?*
No
Yes

If yes, describe
Do you sit for long hours at a workstation, computer or driving?*
No
Yes

If yes, describe
Are you experiencing tension, stiffness, discomfort or pain?*
No
Yes

If yes, describe

Please list any major and/or recent injuries, surgeries, or areas of inflammation.

List any medications you are currently taking:
Do you have sensitive skin?*
No
Yes
Do you have any allergies to oils, lotions, ointments?*
No
Yes

If yes, please explain

List any known allergies

DO YOU HAVE ANY OF THE FOLLOWING CONDITIONS? CHECK ALL THAT APPLY.

MUSCULOSKELETAL
Arthritis/Gout
Bone or joint disease
Disk Problems
Jaw Pain (TMJ)
Lupus
Migraines/Headaches
Osteoporosis
Scoliosis
Spinal Problems
Tendonitis/Bursitis
CIRCULATORY
Heart Condition
Phlebitis/Varicose Veins
Blood Clots
High/Low Blood Pressure
Lymphedema
Thrombosis/Embolism
RESPIRATORY
Breathing Difficulty/Asthma
Emphysema
Sinus Problems
Allergies, specify:
NERVOUS SYSTEM
Chronic Pain
Multiple Sclerosis
Numbness/Tingling
Paralysis
Parkinson's Disease
Pinched Nerve
Seizures/Epilepsy
Shingles
SKIN
Athlete's Foot
Cosmetic Surgery
Herpes/Cold Sores
Rashes
Allergies, specify:
DIGESTIVE
Bladder/Kidney Ailment
Colitis
Crohn's Disease
Irritable Bowel Syndrome
Ulcers
PSYCHOLOGICAL
Anxiety/Stress/ptsd
Depression
Fatigue/Sleep Disorder
OTHER
Cancer/Tumors
Diabetes
Drug/Alcohol/Tobacco Use
Contact Lenses
Dentures
Hearing Aids
Broken/Fractured Bones
Bruise easily
Fibromyalgia
Flu/cold symptoms in the last 24 hours
Infectious Disease
Spasms/Cramps
Stroke
Sprains/Strains

Any other medical condition(s) not listed:

Please explain any of the conditions that you have marked above:
Are you pregnant?*
No
Yes

If yes, how many weeks?

Client Agreement

It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my Practitioner of any changes in my health status. 

Client's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

How did you hear about us?

Who can we thank for referring you? Please enter first and last name of the client that referred you.

MASSAGE PREFERENCES

Have you had a professional massage before?*
No
Yes

If yes, what types of massage have you had (swedish,deep tissue, hot stone, etc)?

Frequency of massages?
What are your goals for treatment?
Relaxation
Pain Relief
Stress Reduction
What type of pressure do you prefer?
Light
Medium
Deep

CURRENT HEALTH


Reason for initial visit
How would you describe your current stress level?
Low
Medium
High
Very High
Do you exercise regularly and/or participate in any sports?*
No
Yes

If yes, what kind of exercise/sports?
Do you perform any repetitive movement in your work, sports or hobby?*
No
Yes

If yes, describe
Do you sit for long hours at a workstation, computer or driving?*
No
Yes

If yes, describe
Are you experiencing tension, stiffness, discomfort or pain?*
No
Yes

If yes, describe

Please list any major and/or recent injuries, surgeries, or areas of inflammation.

List any medications you are currently taking:
Do you have sensitive skin?*
No
Yes
Do you have any allergies to oils, lotions, ointments?*
No
Yes

If yes, please explain

List any known allergies

DO YOU HAVE ANY OF THE FOLLOWING CONDITIONS? CHECK ALL THAT APPLY.

MUSCULOSKELETAL
Arthritis/Gout
Bone or joint disease
Disk Problems
Jaw Pain (TMJ)
Lupus
Migraines/Headaches
Osteoporosis
Scoliosis
Spinal Problems
Tendonitis/Bursitis
CIRCULATORY
Heart Condition
Phlebitis/Varicose Veins
Blood Clots
High/Low Blood Pressure
Lymphedema
Thrombosis/Embolism
RESPIRATORY
Breathing Difficulty/Asthma
Emphysema
Sinus Problems
Allergies, specify:
NERVOUS SYSTEM
Chronic Pain
Multiple Sclerosis
Numbness/Tingling
Paralysis
Parkinson's Disease
Pinched Nerve
Seizures/Epilepsy
Shingles
SKIN
Athlete's Foot
Cosmetic Surgery
Herpes/Cold Sores
Rashes
Allergies, specify:
DIGESTIVE
Bladder/Kidney Ailment
Colitis
Crohn's Disease
Irritable Bowel Syndrome
Ulcers
PSYCHOLOGICAL
Anxiety/Stress/ptsd
Depression
Fatigue/Sleep Disorder
OTHER
Cancer/Tumors
Diabetes
Drug/Alcohol/Tobacco Use
Contact Lenses
Dentures
Hearing Aids
Broken/Fractured Bones
Bruise easily
Fibromyalgia
Flu/cold symptoms in the last 24 hours
Infectious Disease
Spasms/Cramps
Stroke
Sprains/Strains

Any other medical condition(s) not listed:

Please explain any of the conditions that you have marked above:
Are you pregnant?*
No
Yes

If yes, how many weeks?

Client Agreement

It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my Practitioner of any changes in my health status. 

Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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