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Madison Lymphatics & Bodywork

Therapeutic Massage Client Intake Form

"*" indicates required fields

MM slash DD slash YYYY
Name*
Address*

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?*
2. Do you have any difficulty lying on your front, back, or side?*
3. Do you have any allergies to oils, lotions, or ointments?*
4. Do you have sensitive skin?*
5. Are you wearing?*
6. Do you sit for long hours at a workstation, computer, or driving?*
7. Do you perform any repetitive movement in your work, sports, or hobby?*
8. Do you experience stress in your work, family, or other aspect of your life?*
If yes, how do you think it has affected your health?*
9. Is there a particular area of the body where you are experiencing tension, stiffness, pain
10. Do you have any particular goals in mind for this massage session?

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?*
12. Do you see a chiropractor?*
13. Are you currently taking any medication?*
14. Please check any condition listed below that applies to you:
16. Do you need an ADA site?*

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.
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 in 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.