New Patient Evaluation – Massage

mm/dd/yyyy
Where a confirmation text will be sent the day before your session
Please provide the name and phone number of your preferred emergency contact(s)
What's your occupation so I can better understand how you use your body
Tell me about your free time activities so that I may better understand how you use your body
Check all that apply. Note medication(s) taken for EACH condition checked in "Medications, Supplements, Vitamins" section.
This form is CONFIDENTIAL- Please report any transmittable conditions so that your Massage Therapist can take the proper precautions during your massage.
(not required) If you would like tell me more about any of the conditions you checked above please do so here. For example: acute, chronic, frequency, known triggers, etc.
List all that apply to ensure proper precautions are taken. If "none" please note.
List all known food and drug allergies (even if you don't think it applies to massage). If "none" please note.
Note any current surgeries, injuries, and accidents within the last year including approximate dates. If "none" please note.
If yes, was there anything you particularly liked or did not like?
Please check any of the areas you would NOT like me to massage
What depth do you prefer when receiving massage therapy?
(Not required)
If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage/bodywork 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 of which I am aware. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage/bodywork 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 practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for full payment of the scheduled appointment. Understanding all of this, by typing my full name above, I give my consent to receive care.