If you would like to contact me to set up an appointment, here is how. Once scheduled, your appointment will appear on the calendar.
E-mail ~ LoganAHippauf@yahoo.com
Phone ~ (480) 652 4051
Call hours ~ Between 10 am and 6 pm.
If I do not answer, please leave me a message with your name, phone number, the name of the person who referred you if applicable, and the best time to reach you.
All of my first-time clients will be asked to fill out this form upon my arrival. The time taken to fill this out will in no way cut into your massage (the length of which will be discussed when you call to make your appointment). Generally I will arive 15-20 minutes before the massage begins in order to set up as you fill in the form. For repeat clients, I will simply ask questions such as whether anything has changed since your last massage. Thank you for taking the time to look this over, and to be prepared to answer these questions when I arrive.
Massage Intake Form - CONFIDENTIAL INFORMATION
WELCOME! I would like to make your appointment as pleasant and comfortable as possible.
If at any time you have questions regarding your session, please let me know.
Date of birth _____________________________________
State ________________ City _______________
Emergency Contact Name __________________________
Emergency Number _______________________________
Home Phone _______________________ Work Phone _________________________
Have you ever received massage therapy? ____ Yes ____ No
Type of massage experienced (swedish, shiatsu, deep tissue, etc.)_________________________ ______________________________________________________________________________
Are you currently taking any medications? ____ Yes ____ No
If yes, please list name and reason for medications _____________________________________
Are you currently seeing a healthcare professional? ____ Yes ____ No
If yes, please list names and reason/treatment: _________________________________________
Please review this list and check those conditions that have affected your health either recently or in the past.
Place a check mark next to the condition.
Recently In the Past
______ ______ arthritis
______ ______ diabetes
______ ______ blood clots
______ ______ broken/dislocated bones
______ ______ bruise easily
______ ______ cancer
______ ______ chronic pain
______ ______ constipation/diarrhea
______ ______ auto-immune condition*
______ ______ hepatitis (A, B, C, other)
______ ______ skin conditions
______ ______ stroke
______ ______ surgery
______ ______ TMJ disorder
______ ______ depression, panic disorder, other psych condition
______ ______ headaches
______ ______ heart conditions
______ ______ back problems
______ ______ high blood pressure
______ ______ insomnia
______ ______ muscle strain/sprain
______ ______ scoliosis
______ ______ seizures
______ ______ whiplash
______ ______ chemical dependency (alcohol, drugs)
(*AIDS, fibromyalgea, chronic fatigue, lupus, etc.)
If there is anything else to share, please do so: _________________________________________
Do you have any of the following today:
______ skin ______ rash ______ cold/flu ______ open cuts ______ severe pain
______ anything contagious ______ injuries/bruises
If female, are you pregnant? ____ Yes ____ No
Do you have any allergies to:
______ foods (nuts, honey, etc.)
______ environmental allergens (dust, pollen, fragrances)
______ reactions to skin care products
If any of the above are checked, please give details: _____________________________________
Are you wearing: ______ contact lenses ______ hearing aid ______ hairpiece
Please indicate with an X, if any, the areas in which you are feeling discomfort or tightness.
Please indicate with an O, if any, the areas in which you are feeling pain.
Please indicate with an ~, if any, the areas in which you have scar tissue.
What are your goals/expectations for this therapy session? ________________________________
Do you wish to have aromatherapy as part of your massage? (if yes, please fill out the second page)
______ Yes ______ No ______ Maybe, tell me more
The following may sometimes occur during or after massage. They are normal responses to relaxation. Trust and allow your body to express what it needs to:
+ A need to move or change position + sighing, yawning, a change in breathing + stomach gurgling +
+ emotional feelings and/or expression + movement of intestinal gas + energy shifts + falling asleep +
+ memories + possible slight bruising + possible soreness + drink extra water up to 48 hours afterwards +
Please read the following information and sign below:
1. You understand that although massage therapy can be very therapeutic, relaxing and reduce muscular tension, it is not a substitute for medical examination, diagnosis and treatment.
2. This is a therapeutic massage and any sexual remarks or advances will terminate the session and you will be liable for payment of the scheduled treatment.
3. Being that massage should not be done under certain medical conditions, you affirm that you have answered all questions pertaining to medical conditions truthfully.