Client Contact Information
Is this massage/bodywork medically necessary (is it for a medical condition, injury, surgery)? NoYes
Do you have a physician referral/prescription? NoYes
Are you seeking insurance reimbursement?* NoYes
*If yes, please complete the Billing Information form.
Have you ever received professional massage/bodywork before? NoYes
What types of massage/bodywork do you prefer?
What kind of pressure do you prefer? Select...LightMediumFirm
What are your goals/expected outcomes for receiving massage/bodywork?
How do you feel today?
List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):
Do these symptoms interfere with your activities of daily living (e.g., sleep, exercise, work, childcare)? NoYes
List the medications you currently take:
Are you wearing contacts? NoYes
Are you wearing dentures? NoYes
Are you wearing a hairpiece? NoYes
Are you pregnant? NoYes
Have you had any injuries or surgeries in the past that may influence today’s treatment?
Circle any of the following health conditions that you currently have (If you are unsure, please ask):
Blood clotsInfectionsCongestive heart failure Contagious diseasesPitted edema
Please answer honestly, as massage may not be indicated for the above conditions.
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received:
Consent for Treatment
If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage/bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. Understanding all of this, I give my consent to receive care.