Massage Intake Form Name First Last Date of Birth MM slash DD slash YYYY Address Street Address Apt, Bldg, etc. City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneEmail Occupation Emergency Contact First Last PhoneHave you ever received massage therapy? Yes No Are you currently seeing a healthcare professional? Yes No Why? Please list all medications you are taking Add RemoveList one medication per line. Click on the + sign to add more.Do any of the following apply to you today: Open Cuts Injury Cold/Flu Anything Contagious Have you had a fever in the last 24 hours of 100°F or above? Yes No Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath?_ Yes No Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms? Yes No Have you travelled out of state in the last 14 days? Yes No Please check the conditions that apply to you: Broken/Dislocated Bone Skin Condition Chronic Pain Whiplash Low/High Blood Pressure Heart Conditions Blood Clots On Blood Thinner Bruise Easy Headaches Muscle Sprain/Strain Pregnant How many weeks?Please indicate any areas of discomfort: Neck Shoulder Upper Back Lower Back Elbow Forearm Wrist Hand Thigh Knee Shins/Calves Ankles Feet Responses to experience during the massage may include: The need to move/change positions Sighing/Yawning Stomach gurgling Emotional feelings/Memories Falling asleep I understand massage therapy can be very therapeutic, relaxing, & reduces muscle tension, but is not a substitute for medical examination & treatment. This is a therapeutic massage and any sexual remarks or advances will terminate the session and I will be liable for full payment. On occasion, massage should not be done under certain medical conditions; I affirm I have answered all medical questions truthfully. I understand that, because massage therapy work involves maintained touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. By signing this form, I acknowledge that I am aware of the risks involved and give consent to receive massage and bodywork from this practitioner. SignatureDate MM slash DD slash YYYY 31039
