Massage Consent FormPlease answer the questions to the best of your knowledge.Have you had a professional massage before?*YesNoIf yes, how often do you receive massage therapy?*Do you have any difficulty lying on your front, back, or side?*YesNoIf yes, please explain.*Do you have any allergies to oils, lotions, or ointments?*YesNoDo you have sensitive skin?*YesNoDo you wearContact lensesDenturesHearing aidDo you sit for long hours at a workstation, computer, or driving?*YesNoIf yes, please explain.*Do you perform any repetitive movement in your work, sports, or hobby?*YesNoIf yes, please explain*Do you experience stress in your work, family, or other aspect of your life?*YesNoIf yes, how do you think it has affected your health?*Has the stress resulted in:muscle tensionanxietyinsomniairritabilityotherIs there a particular area of the body where you are experiencing tension, stiffness, pain or other discomfort?Do you have any particular goals in mind for this massage session?*YesNoIf yes, please explain.*Check any specific areas you would like the Massage Therapist to concentrate on during the session:PhlebitisDeep vein thrombosis/blood clotsJoint disorder/rheumatoid Arthritis/osteoarthritis/tendonitisOsteoporosisEpilepsyHeadaches/migrainesCancerDiabetesDecreased sensationBack/neck problemsFibromyalgiaTMJCarpal tunnel syndromeTennis elbowPregnancyIf yes, how many months?Medical HistoryAre you currently under medical supervision?*YesNoIf yes, please explain.*Do you see a chiropractor?*YesNoIf yes, how often?*Are you currently taking any medication?*YesNoIf yes, please list.*Please check any condition listed below that applies to you:Contagious Skin ConditionOpen Sores or WoundsEasy BruisingRecent Accident or InjuryRecent FractureRecent SurgeryArtificial JointSprains/strainsSwollen GlandsAllergies/sensitivityHeart ConditionCirculatory DisorderCurrent FeverHigh or Low blood pressureVaricose VeinsAtherosclerosisPlease explain any condition that you have marked above.Is there anything else about your health history that you think would be useful for your massage practitioner to know to plan a safe and effective massage session for you?Draping will be used during the session – only the area being worked on will be uncovered. Clients under the age of 17 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 17.I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any 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 stated all my known medical conditions, and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so.Date* MM slash DD slash YYYY Untitled*I acknowledge that I have read the consent form and understand it.I have been adequately informed with the risks and benefits of this treatment . By ticking the box, I agree to proceed with the procedure.Staff signature ___________________Patient signature ___________________CAPTCHA