embody
Personal Training and Massage Therapy
Toledo, OH
CALL US TODAY @
419-315-5124
TO START GETTING FIT!

Massage Therapy Intake Form
Embody Massage
Jessi Westhoven, Licensed Massage Therapist, Physical Therapy Assistant
CPR certified and insured (by ABMP)
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
____ HIV/AIDS
____ 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: ________________________________________________________________________