Therapeutic Massage Inake Form - Madison Lymphatics & Bodywork

Date of initial visit*

Please Choose Therapist:*

Name*

First Last

Phone (day)*

Phone (evening)

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Date of Birth*

What are your pronouns?

Occupation

Emergency Contact*

Phone*

How Did You Hear About Us?

Please Specify

The following information will be used to help plan safe and effective massage sessions.

Please answer the questions to the best of your knowledge.

1. Have you had a professional massage before?*

Yes

If yes, how often do you receive massage therapy?

2. Do you have any difficulty lying on your front, back, or side?*

Yes

If yes, please explain

3. Do you have any allergies to oils, lotions, or ointments?*

Yes

If yes, please explain

4. Do you have sensitive skin?*

Yes

If yes, please explain

5. Are you wearing?*

Contact lenses

Dentures

Hearing aid

None of the above

6. Do you sit for long hours at a workstation, computer, or driving?*

Yes

If yes, please explain

7. Do you perform any repetitive movement in your work, sports, or hobby?*

Yes

If yes, please explain

8. Do you experience stress in your work, family, or other aspect of your life?*

Yes

If yes, how do you think it has affected your health?*

muscle tension

anxiety

insomnia

irritability

other

If other, please explain

9. Is there a particular area of the body where you are experiencing tension, stiffness, pain

Yes

If yes, please identify

10. Do you have any particular goals in mind for this massage session?

Yes

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.

11. Are you currently under medical supervision?*

Yes

If yes, please explain

12. Do you see a chiropractor?*

Yes

If yes, how often?

13. Are you currently taking any medication?*

Yes

If yes, please list

14. Please check any condition listed below that applies to you:

If yes, how many months?

Please explain any condition that you have marked above*

15. 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?*

16. Do you need an ADA site?*

Yes

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.

Therapeutic Massage Client Intake Form

The following information will be used to help plan safe and effective massage sessions.

Medical History