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Natural Elements Therapeutic Massage


Client Intake & Medical History


Natural Elements Therapeutic Massage, LLC
237 East Center St.
Manchester, CT 06040

Name:     _______________________________________________________
Address:  _______________________________________________________
City/Town: __________________________       State: _____      Zip: _______
Phone: _____-______-______                       Alt. Phone: _____-_____-______
Email: ___________________________________
Occupation: _______________________________
Referred by: _______________________________
Date of Birth: ______________________________


Have you received a massage therapy session before?      YES     NO
If yes, when was your last massage? ________
Where/What therapist preformed the session? ___________________


What are your exercise habits?


What is your posture for the majority of the day?   STANDING   SITTING   BOTH


What is your major complaint or conditions you want to improve?


Has there been a medical diagnosis? By whom? When?


Please list any medications that you are currently taking, including any naturopathic remedies or OTC drugs:




Do you bruise easily?     YES    NO 


In case of emergency, please notify:
Name: _______________________________ Phone: ______-_______-______


Please CIRCLE any of the following conditions that you have/have had:



Circulation Problems                            Hepatitis                           Respiratory
Arthritis               Cold Sweats             Hernia                               Seizures/Epilepsy
Anemia                 Contact Lenses       Joint Problems                 Sinus Problems
Anxiety                Clots                         Skin Conditions
Asthma                Depression               Smoker
                            Osteoporosis                                                                                  Athlete’s Foot     Diabetes                   Muscle Strain/Sprain Stress:
               Bursitis                     Digestive                          Vertebral/Disc Problems:
Blood Pressure (High or Low)             Dizziness/Fainting          Phlebitis
Bursitis                Endocrine Issues     Pacemaker/Pins Other:
Cancer                 Chronic Fatigue        Pregnancy
Cardiac Issues    Headaches                Recent Surgery


I, _________________________________, have stated all conditions that I am aware of and this information is true and accurate, and hereby consent to Mindy L. Neron Perry my participation in massage therapy.
I acknowledge that the therapist is not a physician and does not diagnose illness or disease or any other physical or mental disorder. I clearly understand that massage therapy is not a substitute for a medical examination. It is recommended that I attend my personal physician for any ailments that I may be experiencing prior to my participation in massage therapy. I acknowledge that no assurance or guarantee has been provided to me as to the results of the treatment. I acknowledge that with any treatment there can be risks and those risks have been explained to me and I assume those risks. Having reviewed, discussed, and understood the above information, I further verify that I have not had nor do I now have any medical condition that would render it unadvisable for me to receive massage therapy. I have fully advised the practitioner of all medical conditions for which I receive treatment from any health care provider/phsyician, and warrant that I have disclosed the medications I am currently taking. I understand that I must inform the practitioner of any and all changes to my medical history on a routine basis, and relate all medication changes, accidents, conditions, and/or surgeries to him/her.
I do forever release the practitioner and her insurers, and their respective officers, directors, stockholders, successors, 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 massage therapy.
I also agree to hold harmless and defend the practitioner from all actions, claims, or other legal or administrative action that has arisen or may arise directly out of my participation in massage therapy.


Signature: _______________________________ 

Date: __________

Printed name: ____________________________