Massage Therapy Client Intake Form

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Name
MM slash DD slash YYYY
Are you presently taking any medication?
Have you had a recent major surgical procedure or injury?
Are you currently seeing a Chiropractor, Physical Therapist, or Physician for an ongoing issue?
Please select your stress level:
Are you allergic to any Lotions or Oils?
Musculo-Skeletal
Digestive
Skin
Circulator/Respiratory
Nervous System
Reproductive System
Other Conditions
Consent
I understand that a massage Therapist does not diagnose disease, illness, or prescribe any treatment or drugs, nor do they provide spinal manipulation. I understand that draping will be used at all times. I understand that if I become uncomfortable for any reason that I may ask the Therapist to end the massage session, and they will end the session. I understand that the massage Therapist may end the session for any inappropriate behavior. I have stated all of the conditions that I am aware of, and this information is true and accurate. I will inform the health care provider of any changes in my status.
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