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Massage Intake & Waiver

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SPA SALDO Client Forms

Massage Intake & Waiver

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Personal Information

Full Name *

Email *

Phone

Date of Birth

Age

Address

City / State / Zip

Occupation

Referred By

Emergency Contact

Emergency Contact Name

Phone

Relationship

Massage Information

Have you had professional massage before?

Yes No

How recently?

Reason for massage:

Relaxation Specific Problem

Preferred pressure:

Light Medium Firm

Areas of discomfort

Health History

Please check all that apply:

Areas of swelling Autoimmune disorder Back / neck problems Bleeding disorders Blood clots Bruise easily Bursitis Cancer Contagious condition Decreased sensation Diabetes Fibromyalgia Headaches Heart condition Hypertension Kidney disease Multiple sclerosis Neurological condition Neuropathy Osteoarthritis Osteoporosis Phlebitis Sciatica Seizures Stroke Tendinitis TMJ disorder Varicose veins Vertigo / dizziness

Additional Health Questions

Are you taking any medications?

Yes No

If yes, please list:

Any allergies? (oils, lotions, nuts, fruits, skin, etc.)

Yes No

If yes, please list:

Are you pregnant?

Yes No

How many months? Due date:

Are you currently under medical supervision or receiving interventions?

Yes No

Please describe:

Areas of broken skin? (rash, wounds, etc.)

Yes No

If yes, where?

History of joint replacement surgery?

Yes No

Which joint(s)?

Recent injuries or medical procedures in the past 2 years?

Yes No

Please describe:

Please describe any other injuries or health conditions:

Massage Waiver & Acknowledgment

By signing below, I acknowledge that I am aware of the benefits and risks of massage therapy and have completed this form to the best of my knowledge. I agree to inform my massage therapist of any health or medical changes before receiving treatment.

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savanah@spasaldo.com
+1 (505) 440-6190
501 14th St NW Albuquerque, NM 87104