Menizei Intake Form

A confidential questionnaire shared only with your licensed massage therapist.

All fields are required

Personal Information

First Name
Last Name
Email
Birthday
Gender
Occupation

Contact Information

Physician Name
Physician Phone
Emergency Contact Name
Emergency Contact Phone

Massage History

How would you rate your general health? ( 5 hearts is optimal health, while one heart is dismal health. )
1
2
3
4
5

clear

Reason for Visit
Have you previously had a professional massage?
If yes, when was your last session?
Describe injuries, concerns, or issues to address as well as causes and dates of occurrences.
Describe any treatment you've received for these particular issues.
Describe your treatment goals.

Medical Information

Do you have any of the following cardiovascular concerns?
Congestive heart failure
Embolism
Heart disease
Hemophilia
Low blood pressure
Poor circulation
Varicose veins
Pacemaker
Stroke
Heart attack
High blood pressure
Phlebitis
Thrombosis
None
Do you have any of the following head or neck concerns?
Dizziness
Ear problems
Headaches
Hearing loss
Jaw pain (TMJ)
Migraines
Vision loss
Vision problems
None
Any musculoskeletal concerns?
Arthritis
Osteoporosis
None
Any neurological concerns?
Epilepsy
Sensory loss/change
Artificial joint
Surgical pin/wire
Bursitis
Tendonitis
Multiple sclerosis
Sciatica
Numbness/tingling
Seizures
None
What of respiratory concerns?
Asthma
Emphysema
Smoker
Bronchitis
Chronic cough
Shortness of breath
Sinusitis
Tuberculosis
None
Reproductive
Given birth
Gynecological problems
Pregnant
None
Skin?
Bruise easily
Skin irritations
Skin conditions
Skin infections
None
Miscellaneous concerns?
Anxiety
Cancer
Depression
Diabetes
Digestive conditions
Fibromyalgia
HIV/AIDS
Stress
None

WAIVER

PLEASE READ AND SIGN

I understand that massage therapy is provided for stress reduction, relaxation, relief from muscular tension, and improvement of circulation and energy flow.

I consent to receive massage therapy and understand the nature of the treatment.

If I experience pain or discomfort during the session, I will immediately inform my therapist so that pressure and strokes can be adjusted to my comfort level. I understand and agree to release Menizei LLC and my therapist from any liability for any pain or discomfort I experience during or after the session.

I understand that massage therapy is not a substitute for medical care and that my therapist is not qualified to diagnose, prescribe, or treat physical or mental illnesses.

To the best of my knowledge, I have informed my therapist of all medical conditions and injuries. I agree to inform the therapist promptly of any changes to my health or medical condition. I release Menizei LLC and my therapist from liability should I fail to do so.

I understand that massage therapy is entirely therapeutic and non-sexual in nature.

I understand that all information shared during the session is confidential.

By signing this release, I waive and release Menizei LLC and my therapist from any liability, past, present, and future, relating to massage therapy and bodywork, except in cases of gross negligence or intentional misconduct.

I have read, fully understand, and agree to this consent and release.

SIGNATURE

SUBMIT

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