The Graceful
Touch Massage

Intake Form

303-908-3191

quote:

Within each of us, nature has provided all the pieces necessary to achieve exceptional health and wellness, then left it up to us to put them all together.

Diane Mclaren

 Personal Information:   

       Best Contact:

Name Best Contact Phone:
Address:
City: State:  Zip:
Email: Date of Birth (mm/dd/yyyy): Occupation:
Emergency Contact Phone: Relationship:

The following information will be used to help plan safe and effective massage sessions.
Please answer the questions to the best of your knowledge.

Date of Initial Visit
1. Do you have any difficulty lying on your front, back, or side?
If yes, please explain:

2. Do you have any allergies to oils, lotions, or ointments?
If yes, please explain:

3. Are you wearing  contact lenses dentures a hearing aid ?
4. Do you sit for long hours at a workstation , computer , or driving ?
5. Do you perform any repetitive movement in your work, sports, or hobby?
If yes, please describe
6. On a scale of 1-10, what is your daily stress level?
7. Do you have any particular goals in mind for this massage session?

If yes, please explain

Medical History
In order to plan a massage session that is safe and effective, I need some general information about your medical history.

8. Are you currently under medical supervision for any specific condition?
If yes, please explain
9. Do you see a chiropractor?   If yes, how often?

10. Are you currently taking any medication?
If yes, please list
11. Please check any condition listed below that applies to you:

 contagious skin condition
 open sores or wounds
 easy bruising
 recent accident or injury
 recent fracture
 recent surgery
 artificial joint

 sprains/strains
 current fever
 insomnia

 allergies/sensitivity
 heart condition
 high or low blood pressure
 circulatory disorder
 varicose veins
 arthritis
Type
 osteoporosis

 epilepsy
 headaches/migraines

 cancer
 diabetes
 decreased sensation
 back/neck problems
 Fibromyalgia
 TMJ
 carpal tunnel syndrome
 tennis elbow
 pregnancy If yes, how many months?

Draping will be used during the session – only the area being worked on will be uncovered.
Clients under the age of 17 must be accompanied by a parent or legal guardian during the entire session.
Informed written consent must be provided by parent or legal guardian for any client under the age of 17.
I, (print name) understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage 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 that I am aware of. I understand that massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said during the course of the session given should be construed as such. Because massage 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 therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so.

Approval of client Date (mm/dd/yyyy)
Approval of Massage Therapist Date (mm/dd/yyyy)

                 

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