Health Intake Form

mpgandelman@gmail.com~(203) 499-9076

You will be required to fill out this form before your first session. To save time, you are welcome to print this page, fill it out and bring it with you.

Name: __________________________________________________________________

Address: _____________________________ City: ________________ Zip: ___________

The best phone number to reach you: __________________________________________

E-mail: _________________________________________________________________

Birth date: __________________________ Occupation: ___________________________

How did you hear about me? _________________________________________________

Describe your general diet and exercise habits: ___________________________________

________________________________________________________________________

Describe how well you sleep: _________________________________________________

Describe your general health: ________________________________________________

Have you had a massage before? ______  How long ago? ____________________________

Health History

Have you ever had any surgery or hospitalization? _______  If yes, when? ______________

If yes, please describe: ______________________________________________________

Have you ever been involved in an injury or an accident? _______  If yes, when? _________

If yes, please describe: ______________________________________________________

What kind of care did you receive? _____________________________________________

________________________________________________________________________

Do you have any chronic, ongoing conditions? Yes ____  No ____

If yes, please explain: _______________________________________________________

________________________________________________________________________

Please list any medications/vitamins/supplements you are taking: _____________________

________________________________________________________________________

Are you currently under a doctor’s care? Yes ____  No ____

If yes, please explain: _______________________________________________________

Do you have any skin rashes or other skin problems right now? Yes ____  No _____

If yes, please explain: ________________________________________________________

Have you flown on a plane recently? Yes ____  No ____

What do you hope to accomplish with your visit? ___________________________________ _________________________________________________________________________

Are you pregnant? Yes ____  No ____

Please read the following statements and then sign/initial where indicated.

1. I am aware that draping will be used during the massage session. _____

2. I understand that my feedback is an essential element in my treatment, therefore if at any time I should become uncomfortable during the massage, I may bring it to my therapist’s attention. _____

3. If I am unable to keep an appointment, I understand that a 24-hour notice is required, otherwise, I will be billed the cost of the session. _____

The Massage Treatment given here is for the sole purpose of stress reduction, relief from muscle tension of spasm and to increase circulation and energy flow.

It is my responsibility to explain and discuss all physical conditions with my Massage Therapist so that she may do her job. The Massage Therapist does not diagnose of prescribe

for medical illness, disease, or any other physical or mental disorder.

The Massage Therapist does not do spinal manipulations. Massage Therapy is not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for any ailment that you have.

I have read and I fully understand this form in its entirety. If at any time there are changes

in the information given or in my condition, I will notify my therapist before receiving additional massages.

_________________________________________________        _______________

Client Signature               Date

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