Copy and paste into a word document to complete before coming into your first session to save on time.
Health Intake Form
Dotson Massage & Bodywork LLC
Date of Birth__________________________________Occupation_______________________________________
Emergency Contact Information
Physician Name__________________________ Phone___________________
Cause of Injury or Concern______________________________________________________________________
How long since first notice_______________________________________________________________________
Asthma Shortness of Breath Bronchitis Chronic cough
Blood Clots High Blood Pressure Low Blood Pressure Stroke
Varicose Veins Cardiovascular Accident Heart Disease Pacemaker
Phlebitis Cerebral-vascular Accident Heart Attack Lymphedema
Myocardial Infarction Thrombosis/Embolism Congestive Heart Failure Cold Hands Cold Feet
Bruise Easily Skin Irritations Hypersensitive Reaction Melanoma Skin Conditions
Head & Neck
Ear Problems Migraines Headaches Sinus Problems
Hearing Loss Vision Loss Jaw Pain (TMJD) Vision Problems
Athlete's Foot Respiratory Conditions Hepatitis Skin Conditions Herpes HIV
Gynecological Conditions Pregnancy
Soft Tissue / Joint Dysfunction
Ankles (Left) Feet (Left) Hips (Left) Legs (Left) Mid Back (Left) Shoulders (Left)
Ankles (Right Feet (Right) Hips (Right) Legs (Right) Mid Back (Right) Shoulders (Right)
Arms(Left) Hands (Left) Knees (Left) Lower Back (Left) Neck (Left)Upper Back (Left)
Arms(Right) Hands (Right) Knees (Right)Lower Back (Right) Neck (Right)Upper Back
Cardiovascular Conditions Respiratory Conditions
Allergies Cancer Dizziness Hemophilia Mental Illness
Gout Stress Anaphylaxis Crohn's Disease Epilepsy
Insomnia Osteo Arthritis Rheumatoid Arthritis Arthritis Lupus
Digestive Conditions Diabetes Fibromyalgia Shingles Osteoporosis Loss of Sensation Other Medical Conditions Other Diagnosed Diseases Artificial Joints / Special Equipment Surgical Pins or Wire
Allergies and other conditions your provider should be aware of
Burning Numbness Cerebral Palsy Parkinsons
Herniated Disc Stabbing Multiple Sclerosis Tingling
Medications Please list any medications or drugs you are currently on
Client Waiver form
Please take a moment to read and initial the following information
- I understand that massage therapy is provided for stress reduction, relaxation, relief from muscular tension, and improvement of circulation and energy flow.
- If I experience pain or discomfort during the session, I will immediately inform my therapist so that pressure/strokes can be adjusted to my level of comfort. I will not hold my therapist responsible for any pain or discomfort I experience during or after the session.
- I understand that I should see a physician, chiropractor or other qualified medeical specialist for any mental or physical ailment that I am aware of.
- I understand that the services offered today are not a substitute for medical care. I understand that my therapist is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat physical or mental illness, and that nothing said in the course of the session given should be construed as such.
- Because Massage should not be performed under certain medical conditions, I affirm that I have notified my therapist of all known medical conditions and injuries and answered all questions honestly.
- I agree to inform the therapist of any changes in my health and medical condition. I understand that there shall be no liability on the therapist’s part should I forget to do so.
- I understand that massage is entirely therapeutic and non-sexual in nature. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment.
- By signing this release, I hereby waive and release my therapist from any and all liability, past, present, and future relating to massage therapy and bodywork.
- Draping will be used during the session-only the area being worked on will be uncovered.
- Clients under the age of 16 must be accompanied by a parent or legal guardian during the entire session. Informed written consent must be provided by parent or legal guardian for any client under the age of 18.
- All information provided to Dotson Massage & Bodywork LLC by you, the consumer, will always be kept safe and confidential and will never be sold or abused.
I have read the statement above and agree to all the policies
Client Signature* _____________________________ Date*_______________________________
(If client is under 18 years of age)
Parent/Guardian Signature*________________________________ Date*_______________________________