serenitypdx - serenitypdx

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Referred By (optional)

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What is your primary goal for massage therapy?

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What type of work do you do?

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Please explain any recent (within the past 3 months) issues with soreness, pain, stiffness, or decreased mobility:

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Please explain any chronic issues (issues lasting more than 3 months):

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Do you have any areas that should not be massaged? (Ex. Injured, open wounds, bruises, ticklish)

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Please list any recent or lingering injuries, surgeries, or major illnesses:

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Are you currently under the care of a physician? Please list name of physician and reason:

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Please list any medications, supplements, or herbs you are currently taking and any side effects:

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Are you allergic or sensitive to any scents, oils, or lotions?

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How far along?

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Please describe:

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Intake Agreement(*)

The above information is true to the best of my knowledge. I take full responsibility for making my therapist aware of any changes to my health. I understand that massage therapy is not a substitute for professional medical attention. I understand that massage therapists do not diagnose disease, prescribe medication, or manipulate bones. I understand that sexual misconduct of any kind will not be tolerated. For the comfort of both client and therapist, the client will be draped throughout the entire massage session. No exceptions. I reserve the right to end the massage at any time and so does my massage therapist.

You must agree to this statement in order to receive a massage.

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Intake Form