Remedial Massage Intake Forms

Full Name:

Phone Number:

D.O.B

Email:

example@example.com

Occupation:

Current Medications:

Are you currently under a physician’s care for an acute or chronic illness? If Yes, please explain:

Are you receiving any other Treatments or Therapies (Physiotherapy, Chemotherapy etc):

Please tick any of the following that apply to you:

What exercise/activities do you undertake?:

Reason for consultation:

Affected areas:

How did you hear about us?:

I have chosen to consult with and hereby give consent for remedial massage therapy. I have provided a detailed medical history. I do not expect the therapist to have foreseen any previous or pre-existing condition that I have not mentioned.

I understand that massage provides benefits for certain conditions but are not guaranteed. I also understand that massage therapy may produce side effects such as muscle soreness, mild bruising, increased awareness of areas of pain and light-headedness amongst other possible temporary outcomes.

I am aware that the therapist does not diagnose illnesses, prescribe medications nor physically manipulate the spine or its immediate articulations.

The therapist understands that I have the right to question procedures and to receive an explanation of any procedures that the therapist performs.

I will tell the therapist about any discomfort I may experience during the therapy session and understand that the therapy will be adjusted accordingly.

Signed

Date:

Client History and Consent Form