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MASSAGE INTAKE FORM Date___/___/____ In order to provide you with the best quality massage, please complete this form in its entirety. All information is strictly confidential. Client Name:___________________________________________________ Massage Information: Have you ever received professional massage/bodywork before? Yes ☐ No ☐ How recently? ___________________________________ What kind of pressure do you prefer? Light Medium Firm 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):______________________________________________________________________________________________________________ Do these symptoms interfere with your activities of daily living ( sleep, exercise, work, childcare)? Yes No Explain:________________________________________________________________________________________________________________ Do you wear contacts? Yes___ No___ Are you Pregnant? Yes___ No___ If so, how many months? ________ Dentures? Yes___ No___ Please explain any tension, pain, stiffness, numbness, tightness or discomfort you may be experiencing, and please indicate on the bodies to the left with XXX were it is occurring. ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ 1 MASSAGE INTAKE FORM HEALTH HISTORY Please check any of the following conditions you are experiencing now or have experienced in the past. Please add comments where you feel necessary. Musculoskeletal Spasms/Cramps Sprains/Strains Osteoporosis Gout Osteoarthritis/Rheumatoid Arthritis TMJ (Jaw Pain) Bursitis Plantar Fasciitis Tendonitis Whiplash Syndrome Carpal Tunnel Headache Scoliosis Problems walking Joint Stiffness Other _________________________ Respiratory Pneumonia Sinusitis Asthma Trouble Breathing Dizziness Other _________________________ Circulatory Fainting Cold feet or hands Stroke Pressure Sores Other _________________________ Digestive Ulcers Irritable Bowel Syndrome Colitis Hepatitis Gallstones Crohn’s Disease Diarrhea Gas/Bloating Indigestion Diverticulitis Other _________________________ Skin Fungal Infections Acne Impetigo Dermatitis/Eczema Psoriasis Open Wounds or Sore Rashes Warts/Moles Athletes Foot Cosmetic Surgery Other _________________________ Nervous System Multiple Sclerosis Parkinson’ Disease Cerebral Palsy Spinal Cord Injury Seizure Disorders Numbness/Tingling/Twitching Fatigue Chronic Pain Other _________________________ Other Allergies Insomnia Anxiety/Panic Attacks PTSD Cancer Depression Forgetfulness – Confusion Substance Abuse Chronic Fatigue HIV/AIDs Lupus Kidney disease Bladder Infection Infectious Disease Fibromyalgia Any Other congenital or acquired disabilities____________ ___________________________________ ___________________________________ Surgeries _____________________ ___________________________________ Other ___________________________________ ___________________________________ Anemia Hemophilia Hypertension Low Blood pressure High Blood Pressure Varicose Veins Heart Condition Blood Clots/Phlebitis Diabetes Edema Please list any additional comments regarding your health and well-being: ____________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ 2