Massage Information

Have you received bodywork before?

How recently?

How do you relax?

Please select below to indicate any body parts that you DO NOT want your therapist to work with:

Scalp

Face

Neck

Shoulders

Arms

Hands

Abdomen

Back

Glutes

Feet

Are you on any medications?

If yes, which ones?

Are you under the care of a medical professional or other health-care provider?

If yes, please list:

Have you had any accidents or injuries, been hospitalized or had any surgeries?

If yes, please list:

Do you exercise?

If yes, how often?

Anything you like to add to your movement routine?

List and describe any chronic bodily discomfort:

*Please select any of the following conditions you may currently have:

Others, please specify:

Are you currently pregnant or trying to get pregnant?

If yes, how far along?

I have shared all known medical conditions and physical limitations and will let my massage therapist know if anything changes. I understand that massage therapists do not diagnose medical or mental conditions, prescribe medication, or perform spinal adjustments. Massage therapy is meant to help with relaxation, muscle tension, circulation, and overall body awareness. I understand that I am responsible for seeing a doctor for any medical concerns. I accept full responsibility for any risks related to massage therapy, whether known now or discovered later.

A copy of the Client Bill of Rights is attached for my review, and I understand I may request additional clarification at any time.

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Massage Intake Form

Massage Information