top of page

Client Intake Form – Therapeutic Massage Wellness Center

Personal Information

Date of Birth
Month
Day
Year

The following information will be used to help plan safe and effective massage sessions. Please answer the questions to the best of your knowledge.

Have you had a professional massage before?
Do you have any difficulty lying on your front, back, or side?
Do you have any allergies to oils, lotions, or ointments?
Do you have sensitive skin?
Are you wearing contact lenses dentures a hearing aid?
Do you sit for long hours at a workstation, computer, or driving?
Do you perform any repetitive movement in your work, sports, or hobby?
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?
Is there a particular area of the body where you are experiencing tension, stiffness, pain or other discomfort?
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, HolisticGi Wellness needs some general information about your

medical history.

Are you currently under medical supervision?
Do you see a chiropractor?
Are you currently taking any medication?
Please check any condition listed below that applies to you:

Draping will be used during the session – only the area being worked on will be uncovered. Informed written consent must be provided by parent or legal guardian for any client under the age 17.

I 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 massage 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 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. I understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session. I also understand that the License Massage Therapy reserves the right to refuse to perform massage on anyone whom he/she deems to have a

condition for which massage is contraindicated.

Date
Month
Day
Year
Date
Month
Day
Year
bottom of page