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Includes screening questions on prior massage experience, ability to lie on different positions, allergies and sensitive skin, contact lenses or hearing/vision devices, workstation or driving posture, repetitive movement, and stress impacts. Gathers medical supervision, chiropractic care, medication use, and checked health conditions, plus specific goals and focus areas. 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The client also agrees to notify the therapist of pain or discomfort and understands the confidentiality and non-sexual nature of services, with termination and payment implications for sexual advances or suggestive behavior.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},245768,1790987245,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":79,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":73},549758252649,"https://ap-avatar.wpscdn.com/avatar/8000253669c5317157?_k=1778319167496531819","Client Intake Form – Therapeutic Massage Personal Information:  \nName   Phone (Day)   Phone (Eve)   Address   City/State/Zip   email   Date of Birth   Occupation   Emergency Contact   Phone    \nThe following information will be used to help plan safe and effective massage sessions.  \nPlease answer the questions to the best of your knowledge.  \nDate of Initial Visit   1. Have you had a professional massage before? Yes No  \nIf yes, how often do you receive massage therapy?    \n2. Do you have any difficulty lying on your front, back, or side? Yes No  \nIf yes, please explain   3. Do you have any allergies to oils, lotions, or ointments? Yes No  \nIf yes, please explain   4. Do you have sensitive skin? Yes No  \n5. Are you wearing contact lenses ( ) dentures ( ) a hearing aid ( ) ?  \n6. Do you sit for long hours at a workstation, computer, or driving? Yes No  \nIf yes, please describe   7. Do you perform any repetitive movement in your work, sports, or hobby? Yes No  \nIf yes, please describe   8. Do you experience stress in your work, family, or other aspect of your life? Yes No  \nIf yes, how do you think it has affected your health?  \nmuscle tension ( ) anxiety ( ) insomnia ( ) irritability ( ) other   9. Is there a particular area of the body where you are experiencing tension, stiffness, pain  \nor other discomfort? Yes No  \nIf yes, please identify   10. Do you have any particular goals in mind for this massage session? Yes No  \nIf yes, please explain    \nCircle any specific areas you would like the massage therapist to concentrate on during the session:  \nContinued on page 2  \nMedical History  \nIn order to plan a massage session that is safe and effective,  \nI need some general information about your medical history.  \n11. Are you currently under medical supervision? Yes No  \nIf yes, please explain    \n12. Do you see a chiropractor? Yes No If yes, how often?    \n13. Are you currently taking any medication? Yes No  \nIf yes, please list   14. Please check any condition listed below that applies to you:  \n( ) contagious skin condition  \n( ) open sores or wounds  \n( ) easy bruising  \n( ) recent accident or injury  \n( ) recent fracture  \n( ) recent surgery  \n( ) artificial joint  \n( ) sprains/strains  \n( ) current fever  \n( ) swollen glands  \n( ) allergies/sensitivity  \n( ) heart condition  \n( ) high or low blood pressure  \n( ) circulatory disorder  \n( ) varicose veins  \n( ) atherosclerosis  \n( ) phlebitis  \n( ) deep vein thrombosis/blood clots  \n( ) joint disorder/rheumatoid arthritis/osteoarthritis/tendonitis  \n( ) osteoporosis  \n( ) epilepsy  \n( ) headaches/migraines  \n( ) cancer  \n( ) diabetes  \n( ) decreased sensation  \n( ) back/neck problems  \n( ) Fibromyalgia  \n( ) TMJ  \n( ) carpal tunnel syndrome  \n( ) tennis elbow  \n( ) pregnancy If yes, how many months?  \nPlease explain any condition that you have marked above    \n15. Is there anything else about your health history that you think would be useful for your massage practitioner to know to plan a safe and effective massage session for you?    \nDraping will be used during the session – only the area being worked on will be uncovered.  \nClients under the age of 17 must be accompanied by a parent or legal guardian during the entire session.  \nInformed written consent must be provided by parent or legal guardian for any client under the age of 17.  \nI,   (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 spin","cbCaidkuLDa8o7IS","https://ap.wps.com/l/cbCaidkuLDa8o7IS","pdf",112796,"English","# Client Intake Form - Therapeutic Massage Personal Information\n## Personal Information and Initial Visit\n## Intake Screening Questions\n## Medical History\n## Consent, Waiver, and Acknowledgments","[{\"question\":\"What personal and emergency contact information is collected on the form?\",\"answer\":\"The form requests the client’s name, phone numbers (day/evening), address, city/state/zip, email, date of birth, occupation, emergency contact name, and emergency contact phone.\"},{\"question\":\"What medical history details are required for safe massage planning?\",\"answer\":\"The form asks whether the client is under medical supervision, whether they see a chiropractor, whether they take medication, and a checklist of applicable health conditions (e.g., skin conditions, open wounds, fractures, surgery, joint issues, heart conditions, and more).\"},{\"question\":\"What consent and waiver does the client acknowledge?\",\"answer\":\"The client acknowledges massage and holistic practitioners are not medical doctors and that massage is for relaxation and relief of muscular tension, not medical diagnosis or treatment. The client also agrees to notify the therapist of pain or discomfort and understands the confidentiality and non-sexual nature of services, with termination and payment implications for sexual advances or suggestive behavior.\"}]","Client Intake Form - Therapeutic Massage Personal Information - Informed Consent | PDF",1789230986]