Massage Consent Form Please answer the questions to the best of your knowledge.Have you had a professional massage before?* Yes No If yes, how often do you receive massage therapy?* Do you have any difficulty lying on your front, back, or side?* Yes No If yes, please explain.* Do you have any allergies to oils, lotions, or ointments?* Yes No Do you have sensitive skin?* Yes No Do you wear Contact lenses Dentures Hearing aid Do you sit for long hours at a workstation, computer, or driving?* Yes No If yes, please explain.* Do you perform any repetitive movement in your work, sports, or hobby?* Yes No If yes, please explain* Do you experience stress in your work, family, or other aspect of your life?* Yes No If yes, how do you think it has affected your health?* Has the stress resulted in: muscle tension anxiety insomnia irritability other Is 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?* Yes No If yes, please explain.* Check any specific areas you would like the Massage Therapist to concentrate on during the session: Phlebitis Deep vein thrombosis/blood clots Joint disorder/rheumatoid Arthritis/osteoarthritis/tendonitis Osteoporosis Epilepsy Headaches/migraines Cancer Diabetes Decreased sensation Back/neck problems Fibromyalgia TMJ Carpal tunnel syndrome Tennis elbow Pregnancy If yes, how many months? Medical HistoryAre you currently under medical supervision?* Yes No If yes, please explain.* Do you see a chiropractor?* Yes No If yes, how often?* Are you currently taking any medication?* Yes No If yes, please list.* Please check any condition listed below that applies to you: Contagious Skin Condition Open Sores or Wounds Easy Bruising Recent Accident or Injury Recent Fracture Recent Surgery Artificial Joint Sprains/strains Swollen Glands Allergies/sensitivity Heart Condition Circulatory Disorder Current Fever High or Low blood pressure Varicose Veins Atherosclerosis Please 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 ___________________
