Personal Data

Massage History/Treatment Information

Current Medications, Herbals & Supplements and reason for use. Please include OTCs such as aspirin, ibuprofen, Claritin, etc.

Previous History (Include year & treatment received)

Health History

Consent & Contract for Care

It is my choice to receive massage therapy and I give my consent to receive treatment. I have completed this form to the best of my knowledge and will inform the massage therapist of any change in my physical health. I understand that a massage therapist cannot diagnose illness, disease, or any other medical, mental, or emotional disorder. Nor do they prescribe medical treatment, pharmaceuticals, or perform spinal thrust manipulations. I realize that the treatment is being
given for the well being of my body, mind and spirit. This includes stress reduction, relief from muscular tension, spasm or pain, also for increasing circulation or energy flow. I agree to communicate with my practitioner any time I feel like my wellbeing is compromised. I acknowledge that massage is not a substitute for medical examination or diagnosis; I am responsible for consulting a qualified physician for any physical ailments that I have.

I understand that massage therapy is a therapeutic health aide and is non-sexual.