Massage/Thai Yoga Therapy/CranioSacral Intake Form

Personal Information
1. Date of Birth:
2. Occupation:
3. Employer:
4. Primary Physician:
5. Emergency Contact: *
6. Emergency Contact Relationship: *
7. Emergency Contact Phone: *
8. How did you hear about us?
Medical Information
9. Are you taking any medications? *
10. If yes, please list name and use:
11. Are you currently pregnant? *
12. If yes, how far along:
13. Any high risk factors?
14. Do you suffer from chronic pain? *
15. If yes, please explain:
16. What makes it better?
17. What makes it worse?
18. Have you had any orthopedic injuries? *
19. If yes, please list:
20. Please indicate any of the following that apply to you: *
21. Explain any conditions you have marked above:
22. Are there any other conditions that not listed above? *
23. Have you had a professional massage before? *
24. What pressure do you prefer? *
25. Do you have any allergies or sensitivities? *
26. If yes, please explain:
27. What are you goals for this treatment session? *
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 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.

I affirm that I have notified my therapist of all known medical conditions and injuries.

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.

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.

I have received the policy statement, and have read and agree to the policies therein.
By signing below, I agree that all the information above is true. *
Information and Suggestions
  • Prior to your massage, please remove contact lenses and all jewelry. Pull long hair back with a clip or band.
  • In general, massage is given while you are unclothed. However, you may choose to wear undergarments or a swimsuit. You will be covered with a top sheet throughout your session. This is your massage and you should be as comfortable as possible.
  • Certain types of massage (shiatsu, cranial sacral therapy, reflexology, Thai massage) require loose, comfortable clothing that allow for freedom of motion.
  • Feel free to ask your therapist any questions before, during, or after the session. Your therapist is a highly trained professional and will be happy to make you feel informed and comfortable