Massage Intake Form Name * First Name Last Name Phone * (###) ### #### Email * Date of Birth MM DD YYYY Emergency Contact Name and Phone * How did you hear about Mountain Laurel Massage? * Friend / Colleauge Web search Social Media Are you taking any medications? If yes, please list. * Are you pregnant? If yes, how many weeks? * Do you suffer from chronic pain? If yes, please explain. * Do you have any allergies/aversions to oils, creams, lotions or smells? If yes, please explain. * Please mark any that apply to you * Cancer Headaches/Migraines Arthritis Diabetes Joint Replacements High/Low Blood pressure Neuropathy Fibromyalgia Stroke Heart Attack Kidney Disfunction Blood Clots Numbneess Sprains or Strains Contagious Skin Condition Varicose Veins Easy Bruising Scoliosis Epilepsy TMJ Discomfort Carpal Tunell Syndrome Plantar Fasciitis Osteopenia/Osteoporosis Dizziness or Fainting None Are there any areas you want me to avoid? * Have you had any recent injuries? If yes, please explain. * Have you had surgery in the last 3 months? Please explain. * Any additional information you would like me to know? Medical Waiver * I understand that therapeutic massage is not a substitute for traditional medical treatment or medications. I understand that the massage therapist does not diagnose illnesses or injuries, or prescribe medications. 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. 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. I understand that I or the massage therapist may terminate the session at any time. I understand and I agree that I am receiving massage therapy entirely at my own risk. Electronic Signature * By typing your full name in the box below, you indicate that all information submitted on this form is correct to the best of your knowledge. Thank you!
