Hill Country Healing Arts & Massage

Healing The Hill Country since 2002

Massage Intake Form

Massage Intake Form
 Personal Information
Name ________________________________________ Phone (day) _____________________ (evening) _____________________ Address _____________________________________ City/State/Zip _________________________________ DOB ___________ Occupation ___________________________________________________________________________________ Email____________ Primary Physician _______________________________________ Emergency Contact ____________________________________ Relationship __________________ Phone __________________ How did you hear about us? ____________________________________________________________________________________
     Medical Information
Are you taking any medications? ☐ yes ☐ no
If yes, please list name and use: _____________________ _______________________________________________
Are you currently pregnant? ☐ yes ☐ no
If yes, how far along? ______________________________ Any high risk factors? ______________________________
Do you suffer from chronic pain? ☐ yes ☐ no
If yes, please explain ______________________________ What makes it better? _____________________________
_______________________________________________ What makes it worse? ____________________________ _______________________________________________
Have you had any orthopedic injuries? ☐ yes ☐ no
If yes, please list: ________________________________
Please indicate any of the following that apply to you.
Massage Information
Have you had a professional massage before? ☐ yes ☐ no What type of massage are you seeking?
☐ Relaxation ☐ Therapeutic/Deep Tissue Other ___________________________________________ What pressure do you prefer?
☐ Light ☐ Medium ☐ Deep
Do you have any allergies or sensitivities? ☐ yes ☐ no
Please explain ________________________________
Are there any areas (feet, face, abdomen, etc.) you do not want massaged? ☐ yes ☐ no
Please explain _______________________________ What are your goals for this treatment session?
_____________________________________________ Please circle any areas of discomfort
By signing below, you agree to the following.
I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time.
Client Signature __________________________ Date __________ Therapist Signature _______________________ Date __________
       ☐ Cancer
☐ Headaches/Migraines
☐ Arthritis
☐ Diabetes
☐ Joint Replacement(s)
☐ High/Low Blood Pressure ☐ Neuropathy
☐ Fibromyalgia
☐ Stroke
☐ Heart Attack
☐ Kidney Dysfunction ☐ Blood Clots
☐ Numbness ☐Sprains or Strains
  Explain any conditions you have marked above:
________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________

General Liability Release Form
By signing below, you agree to the following:
1) I give my permission to receive massage therapy.
2) I understand that therapeutic massage is not a substitute for traditional medical
treatment or medications.
3) I understand that the massage therapist does not diagnose illnesses or injuries,
or prescribe medications.
4) I have clearance from my physician to receive massage therapy.
5) I understand the risks associated with massage therapy include, but are not limited to:
• Superficial bruising
• Short-term muscle soreness
• Exacerbation of undiscovered injury
I therefore release the company and the individual massage therapist from all
liability concerning these injuries that may occur during the massage session.
6) I understand the importance of informing my massage therapist of all medical conditions and medications I am taking, and to let the massage therapist know about any changes to these. I understand that there may be additional risks based on my physical condition.
7) I understand that it is my responsibility to inform my massage therapist of any discomfort I may feel during the massage session so he/she may adjust accordingly.
8) I understand that I or the massage therapist may terminate the session at any time.
9) I have been given a chance to ask questions about the massage therapy session and my questions have been answered.
_________________________________ ____________ Signature Date