Seattle Massage LMP: Sangraal Bodywork intake form

Name
Address
State/ City / Zip:
Home phone
Work phone
Email:
Birthdate:
Occupation
Primary Physician:
Emergency contact	Name Phone
Referred by

Have you ever had a professional massage before?		Yes No
What other ways do you relieve stress?		type here
Do you exercise regularly or play sports?		Yes No
If so, what sort and how often?		type here
Are you now taking care from a health provider for any condition?		Yes No
Please describe		type here
Do you take any medication (incl. Aspirin, ibuprofen, etc.) regularly, or today?		Yes No
Please specify dosage		type here
Do you have any skin problems/allergies?		Yes No
Please describe		type here
Have you ever had surgery?		Yes No
Please describe		type here
Have you ever had any serious injuries, accidents, or illnesses?		Yes No
Please describe		type here
Have you ever had cancer?		Yes No
Please describe		type here
Do you have high or low blood pressure?		high low no
If so, how is it controlled?		type here
Do you have arthritis?		Osteo Rheumatoid
Where is it located?		type here
Do you have any spinal problems?		Yes No
Please specify		type here
Do you have any infectious or contagious conditions?		Yes No
Please describe		type here
Are you experiencing sleep disorders at this time?		No Yes
Please describe		type here
Are you pregnant?		Yes No
At what stage? Describe any complications		type here
Do you wear:		contact lenses dentures hearing aids
Do you have any other medical condition that I should be aware of before the session?		type here
Do you have any needs that require special attention or accommodation? Please describe		type here
Do you want specific results from your massage? Please specify		type here
Are there any parts of your body that are too painful to touch, or that you would prefer not to be massaged?		type here

I have chosen to receive massage therapy. I understand the massage is being given for the well being of my body and mind. This includes stress reduction, relief from muscular tension, spasm, or pain, or for increasing circulation or range of motion. I agree to communicate with my practitioner at any and all times that I feel my well being is being compromised. I understand that massage therapists do not diagnose illness or injury, prescribe pharmaceuticals, or perform chiropractic spinal thrust manipulations. I understand that massage therapy is not a substitute for any of these services, and that I should see a primary care provider for their provision. I have stated all medical conditions that I am aware of and will update the massage therapist of any changes in my health status. I acknowledge the policy of Sangraal Bodywork regarding the cancellation of scheduled appointments: that no less than 24 hours notice is required or the full fee for the session may be levied at the discretion of the therapist.
Date

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