Indigo Blue Massage & Wellness - MEDICAL INTAKE FORM

Indigo Blue Massage & Wellness - Holistic Healing Massage & Reiki Services

Indigo Blue Massage & Wellness

Medical Intake Form

Please fill out the following Medical Intake Form before your appointment with us. Thank you.

Date

Your Name

Your Address

Your Phone No.

Birthday

Your E-mail Address:

Medical History & Medications Currently Taking

Any injuries or recent surgeries we should know about? Please be specific with type of injury and when the surgery took place.

What type of massage are you looking to receive from us?

What would make this massage session a success for you?

Do you understand that you will be draped at all times?
Yes
No

Do you have any comments or questions you would like to relay to the Therapist?

Do you have any allergies from oils or creams that may be used on the skin?

Do you have high blood pressure?

Are you pregnant?

Do you have varicose veins?

Do you have any contagious diseases?

Do you have osteoporosis?

Any broken bones in the past two years?

Do you bruise easily?

Any injuries in the past two years?

Do you suffer from arthritis? Do you have tension or soreness in a specific area? Please specific.

Do you have cardiac or circulatory problems?

Do you suffer from back pain?

Do you have numbness or stabbing pains?

Are you sensitive to touch or pressure in any area?

Any other medical conditions or medications you think I should know about?

I understand that I will be receiving massage therapy as a form of adjunctive health care only and that this therapy is not intended to replace appropriate medical care. I do forever release the practitioner and her insurers, and their respective officers, directors, stockholders, successors, employees and agents from all liability of any nature whatsoever, whether past, present or future for any injury or damage which may occur to myself or my family as a result of my participation in this therapy. I also agree to hold harmless and defend the practitioner from all actions, claims, or other legal or administrative action that arises or may arise directly or indirectly out of my and my child’s participation in massage therapy. Please sign your name in the given field below.