Please fill in the form below and print it out to bring with you to your appointment.

                                                                                        Massage Sanctuary

Massage Therapy Intake Form

Name: ____________________________________Date: ________________________

Address: __________________________________Postal Code: __________________

Home Phone: ________Cell Phone:_________________

Email: _______________________________DOB: _____________________________

Occupation: ____________________________ Referred By: _____________________

Other Healthcare Practitioners: ______________________________________________________________________

Present injury or problem:__________________________________________________

Started when:___________________________________________________________

What action recreates pain:____________________eases pain:___________________

Does pain radiate?____________________Where?_____________________________

Past injuries:_________________________________________When:______________

______________________________________________________________________

Medications you now take and any side effects you experience:

Name of drug:                          Dosage/day:                              Reasons for taking:

______________________________________________________________________

______________________________________________________________________

Hospitalizations: ______________________________________________________________________

Check any of the following that apply:

_____ Arthritis               _____TMJ Syndrome                 _____ Cold hands and feet

_____ Headaches             _____ Fever                             _____ High Blood Pressure

_____ Varicose Veins    _____ Flu or Cold                    _____ Insomnia

_____ Inflammation             _____ Infection                                    _____ Contagious disease

_____ Cancer                  _____ Diabetes                                     _____ Epilepsy/Seizures

_____ Skin Problems            _____ Stroke                           _____ Low Blood Pressure

_____ Muscle Spasms _____ Lower Back Pain             _____ Circulatory Problems

______Fatigue                _____Grinding of teeth                _____ Weakness in parts of body

Chronic pain (where?) ____________________________

Allergies (including oils and or/creams or essentila oils) ______________________________________________We use primarily unscented organic oil but also incorporate spot treatments with essential oils.  Please let us know if you allergic to any of the following by circling the  it :  rose, lavender, chammomile, cayenne, ginger, tea tree, mint,  balsam, nutmeg, clove, black pepper, vervain, pine, lemon, orange.

Appliances (Screws, Pacemakers, etc.) _____________________________________________

_____ Pregnant ___________ Due Date_____ New Mother ________ Nursing

Other conditions you feel may affect your treatment: _____________________________________________________________________________

_____________________________________________________________________________

When was your last Massage Therapy treatment?___________________________________

Therapeutic Massage Waiver

I understand that massage therapy is an aid to health but does not take the place of any care my Medical Doctor may recommend. I have given correct information regarding my health and am not aware of any reason for not having massage therapy.

I understand that payment is expected at the time of visit unless previous arrangements have been made, and that if I fail to cancel an appointment 24 hours in advance, I will be charged for the missed appointment.

Signature: __________________________________ Date:_________________

 
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