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Client Intake Form

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    Emergency Contact

    Referred By:

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    May we email you?

    Medical Information

    Depending on the service you are receiving, some of these questions may not pertain to you. However, we like to have this information for potential future use. Please check Yes or No. If yes, please briefly explain below

    Have you had a professional massage before?

    If yes, how long ago?

    Are you pregnant?

    If yes, how many weeks are you?

    If you are pregnant, is your pregnancy high risk?


    Are you taking any medications?

    If yes, please list:

    Have you had any recent surgeries?

    If yes, please list:

    Have you ever had any broken bones or concussions? If yes, please explain below.


    Any recent accidents, falls or injuries? If yes, please explain below.

    Do you bruise easily?

    Do you have diabetes?

    Do you have arthritis?

    Do you have high blood pressure?

    Do you have any contagious diseases or fungus? If yes, please explain below.

    Epilepsy or seizures?

    Cardiac or Circulatory problems? If yes, please explain below.

    Do you have varicose veins?

    Do you suffer from joint swelling?

    Osteoporosis?

    Have you ever been diagnosed with TMJD (Temporal Mandibular Joint Disorder)?

    Do you suffer with jaw muscle pain?

    Do you suffer from headaches/migraines? If yes, where and how often? Please explain below.

    Do you have tension or soreness in specific areas?

    Back/neck pain?

    Do you suffer from depression?

    Do you suffer from anxiety?

    Have you consumed alcohol today?

    Do you have any allergies to nuts, oils or scents?

    If yes, please list:

    What results are you hoping to get out of your appointment today? Also, if you answered yes to any of the above questions, please provide details.

    About Your Massage

    What type of pressure is comfortable for you?

    Please select one of the following:

    Would you like aromatherapy at no extra charge?

    To best protect your health and the health of others, please fill out this form before each massage and bodywork session. Thank you!

    Please check if you are experiencing any of the following as a NEW PATTERN since the beginning of the pandemic:

    Do you have any new discomfort with exertion or exercise?

    Contact/Agreement

    I understand that the massage/bodywork I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage or bodywork should not be considered as a substitute for medical examination, diagnosis or treatment, and that I should see a physician or other qualified medical specialist for any mental or physical ailments that I am aware of. I understand that massage/bodywork practitioners 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 this session given should be constructed as such. Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all known medical conditions, and answered all questions honestly. I agree to keep the practitioner informed and updated to any changes in my medical profile. I understand that there shall be no liability on the practitioner’s part if I fail to do so, and that Harmony Within Massage Therapy is not liable for any discomforts, injuries or perceived injuries that may occur. I also understand that any illicit or sexually suggestive remarks or advances made by me will suit in immediate termination of the session, possible legal action, and I will be liable for payment of the terminated appointment. I understand that Harmony Within Massage Therapy enforces a 24 hour cancellation policy and that if I do not give 24 hours notice of cancellation, I will be liable for payment of the appointment.

    Massage and bodywork therapy practices are designed to promote and maintain the health and well-being of the client. Massage and bodywork therapies do not include the diagnosis of illness, disease, impairment, or disability. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or manipulations may be adjusted to my level of comfort.

    Because massage and body work therapy may be contraindicated due to certain medical conditions, I affirm that I have informed the therapist of all my known medical conditions and will keep the therapist updated as to any changes in my medical condition.

    Today's Date*:(mm-dd-yyyy)

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