Intake Health Declaration

Please fill out the following form.

First name

Last name

Email

Multi-line address

Country/Region

Address

City

Zip / Postal code

Phone

Date of birth

Month

Day

Year

Emergency Contact- if something happens where you are incapacitated, I will call 911 and then the Emergency Contact Listed to inform them which hospital you may be at. * Please include Name + Relation

EMERGENCY PHONE

Occupation/ Hobbies: identify patterns of repetitive strain, postural issues, or physical demands

ALLERGIES/SENSITIVITIES: (OILS, LOTIONS, NUTS, FRUITS, SKIN, ETC)

Have you been hospitalized in the last 12 months? And/Or Do you have an Active Infection? Or areas of broken skin?

No

Yes

Are you suffering from a medical condition, illness or injury? Any current infectious or contagious conditions? (HIV, TB, fungal infections, shingles, warts, etc)

No

Yes

If you answered yes to any of the questions above, please supply additional information. Including Dates/Reason for Visits

Blood Thinners and Anticoagulants These heighten bruising and bleeding risks, making deep tissue work contraindicated; opt for light Swedish or avoid entirely without clearance.

Anti-Inflammatories and Pain Relievers Increase bruising susceptibility and may mask pain signals, leading to over-treatment.

NSAIDs (e.g., ibuprofen, naproxen).

Corticosteroids (e.g., prednisone).

Narcotic pain relievers or muscle relaxants.

Multi Blood Pressure Medications Can cause hypotension, dizziness, or orthostatic issues during position changes.

Antihypertensives (e.g., ACE inhibitors, beta blockers, calcium channel blockers, diuretics)

History of joint replacement surgery, recent injuries, medical procedures in the past 2 years, Please describe any other injuries or health conditions:

Initials

By submitting this form, I acknowledge that I am aware of the benefits and risks of massage therapy and that I have completed this form to the best of my knowledge, it is accurate and complete. I also agree to inform my massage therapist of any health or medical changes.