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Massage Therapy Intake Form


Embody Massage


Jessi Westhoven, Licensed Massage Therapist, Physical Therapy Assistant 


CPR certified and insured (by NACAMS)

Licensed by the Ohio State Medical Board and the Physical Therapy section of the OTPTAT Board of Ohio


Health Questionaire

Name: ___________________________________  Occupation: _________________________

Address: __________________________ City: _____________ State: _____ Zip: ___________

Daytime Phone: (_____) _________________  Evening Phone: (_____) __________________

Email Address: ______________________________________________ DOB: _____________


Emergency Contact: ____________________________ Phone: (_____) __________________




Massage Experience


How did you hear about us? _____________________________________________________


Have you ever had a professional massage before?  Y /  N


If yes, when was your last massage? _______________________________________________


What type of massage? (ex. Swedish, Deep Tissue, etc) _______________________________


What is your goal for today? _____________________________________________________


What type of pressure do you like? (Please Circle)  Light—-Medium—-Firm—-Deep


Are you uncomfortable with any of the following areas to be massaged:


Gluteal Region  (Y/N)          Pectoral Region  (Y/N)             Face/Scalp  (Y/N)             Feet  (Y/N)




Health History


Please list any medications or supplements you are currently taking and explain: _________________________________________________________________________________________






Please list any injuries/accidents/illnesses still affecting you: _______________________________________






Please list any surgeries and explain: __________________________________________________________






Please identify the areas of concern or goals for the session: _________________________________________________________________________________________





Health History


Please indicate any Present (P), Past (X), or Reoccurring (C) conditions:




____ ADD/ADHD                                                                      ____ Mononucleosis


____ Allergies                                                                          ____ Multiple Sclerosis


____ Alzheimer’s disease                                                        ____ Muscular Dystrophy


____ Anxiety disorder                                                              ____ Numbness/ Tingling


____ Arthritis                                                                           ____ Osteoporosis/Osteopenia


____Osteoarthritis                                                                   ____ Pain


____ Rheumatoid Arthritis                                                       –Location: ____________________


____ Athletes foot                                                                    –Muscular or Joint: _____________


____ Asthma                                                                            — Chronic?  Y/N


____ Blood Clot/ Deep Vein Thrombosis/                               ____ Paralysis


Phlebitis/ Embolism                                                                 ____ Parkinson’s disease


____ Broken or fractured bones                                              ____ Pregnancy


____ Bursitis                                                                            ____ Psoriasis


____ Cancer                                                                             ____ Rash


–Location: ___________________                                         ____ Sciatica


–Treatment: __________________                                        ____ Scoliosis


– In Remission?  Y/N                                                               ____ Seizure


____ Carpal Tunnel Syndrome                                                ____ Sleeping problems


____ Cerebral Palsy                                                                ____ Spasms/ Cramping


____ Chronic Fatigue Syndrome                                             ____ Strain/ Sprain


____ Contagious condition                                                     ____ Stroke


____ Crohn’s disease                                                              ____ Tendonitis


____ Depression                                                                      ____ Thyroid issues


____ Diabetes                                                                          ____ TMJ/ Jaw Pain


____ Type I                                                                               ____ Tumor


____ Type II                                                                             –Location: ____________________


____ Diverticulitis                                                                   –Malignant or Benign? ___________


____ Eczema                                                                            ____ Varicose Veins


____ Epilepsy                                                                           ____ Visually impaired


____ Epstein Barr                                                                     ____ Other: _________________________


____ Fertility Concerns                                                                                  


____ Fibromyalgia                                                                                      


____ General Fatigue                                                                                 


____ Gout                                                                                                     


____ Headaches


–Type: _____________________


–Frequency: ________________


____ Hearing Impairment


____ Heart Condition


____ Herpes/ Shingles


____ High/ Low Blood Pressure


____ High/ Low Cholesterol




____ Infection


____ Lupus


____ Lymphedema




Informed Consent


By signing this, I agree that I have answered all questions to the best of my knowledge and that I will inform the therapist of any changes in my condition or medication. If I experience any pain/discomfort or would like the pressure adjusted, I will inform the therapist immediately.



I understand that a massage therapist cannot diagnosis any illness, disease, or any physical or mental disorders nor can the therapist prescribe any medication and that nothing said in a session should be construed as such. I understand that massage therapy is intended to work in conjunction with my health care, not act as a substitute for medical examination.  I understand that it is my responsibility to consult a physician for any ailments I may have.



I understand that massage therapy is a therapeutic measure used to reduce stress, muscular tension, and pain. I understand there are no guarantees for recovery and if I am unsatisfied with the progress made with my treatment I will inform the therapist, so he/she may direct me to another treatment. I also understand that massage therapy is non-sexual in nature and any advancement made will terminate the massage.



I agree to abide by a 24 hour cancellation notice for any scheduled massage. I understand I may be charged up to the full amount of service for missed appointments or for any cancellations with less than a 24 hour notice. I understand that walk-ins are welcome, but does not guarantee the availability for a massage. I understand that if I arrive late for an appointment, the session will end at the original scheduled time to prevent penalizing another client. However, if the massage therapist is late, he/she will fulfill the scheduled massage length or offer a reasonable compensation.



I understand that if I use a coupon during my visit, it is not valid with any other coupons or promotions.



I agree that I am of legal age (18 years old) and that if I am not, I agree to have my parent or guardian sign a parental/guardian release form before treatment.



I understand that certain conditions or medications may contraindicate (not permit) massage or may require the use of alternate techniques or pressure. I respect the decision of the massage therapist and am fully prepared to reschedule the massage for a later date if requested by the massage therapist. I also understand that massage may be advisable by my physician, but not by a massage therapist. In that event, I agree to provide a written agreement from my physician before proceeding with treatment.






Print Name: __________________________________________________________________






Signature: ____________________________________________________________________






Date: ________________________________________________________________________

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