La Dolce Vita Client Intake Form
Name_____________________________________
□ Male □Female
Phone_______________________
Phone Provider___________________________Address_______________________________________________
City/State/Zip___________________________________________Email__________________________________
DOB_____________Ocupation____________________________Referred by______________________________
Emergency Contact_________________________________________________Phone_______________________
Have you ever experienced a professional massage or bodywork session? □ Yes □ No
Do you have sensitive skin? □ Yes □ No
Are you wearing □ contact lenses □ dentures □ hearing aid?
Do you sit for long hours at a workstation, computer, or while driving? □ Yes □ No
If yes, please describe__________________________________________________________________
5. Do you perform any repetitive movement in your work, sports, or hobby? □Yes □ No
If yes, please describe__________________________________________________________________
6. Do you have any particular goals in mind for this massage session? □ Yes □ No
If yes, please describe__________________________________________________________________
7. Are you currently under medical supervision? □ Yes □ No
If yes, please explain___________________________________________________________________
8. Do you see a chiropractor? □ Yes □ No If yes, how often?__________________________________________
9. Are you currently taking any medication(s)? □ Yes □ No
If yes, please list______________________________________________________________________
10. Do you have an implanted medical device(s) □ Yes □ No
If yes, please list______________________________________________________________________
1.
2.
3.
4.
Please check all boxes that apply to you. If you have a specific medical condition or specific symptoms, your
massage/bodywork may be contraindicated. A referral from your primary care provider may be required prior to
service being provided.
Place an X on the area you would like the
□ Stress
□ Artificial Joint(s)
massage therapist to concentrate on
□ Migraines/headaches
□ Carpal Tunnel Syndrome
during the session
□ TMJ
□ Cysts/Tumors
□ Fibromyalgia
□ Sciatica
L
R
□ Diarrhea
□ Menstrual Problems
□ Allergies
□ Skin Rashes
□ Sinus Problems
□ Urinary Problems
□ Heartburn
□ Contagious Skin Condition
□ Varicose Veins
□ Open Sores or Wounds
□ Diabetes
□ Easy Bruising
□ Knee Problems
□ Recent Accident or Injury
□ Cancer
□ Recent Fracture
□ Osteoporosis
□ Sprains/Strains
□ High/Low Blood Pressure
□ Current Fever
□ Epilepsy or Seizures
□ Swollen Glands
□ Joint Pains
□ Atherosclerosis
□ Heart Problems
□ Phlebitis
□ Circulatory Problems
□ Deep Vein Thrombosis/Blood Clots
□ Constipation
□ Joint Disorder/Rheumatoid Arthritis/Osteoarthritis/Tendonitis
□ Back/Neck Pain
□ Decreased Sensation
□ Shoulder/Rotator Cuff
□ Tennis Elbow
□ Athlete’s Foot
□ Pregnancy If yes, how many weeks/months?_________________________
□ Broken Bones
Other:___________________________________________________________
Recent Surgeries/Injuries:________________________________________________________________________
I, (print name)_________________________________________understand that the massage I receive is provided
for the basic purpose of relaxation and relief of muscle tension. If I experience any pain or discomfort during
this session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to
my level of comfort. I further understand that the massage should not be construed as a substitute for a medical
examination, diagnosis, or treatment and that I should see a physician, chiropractor or other qualified medical
specialist for any mental or physical ailment that I am aware of. I understand that massage therapists are not
qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and
that nothing said during the session given should be construed as such. Because massage should not be performed
under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all
questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand
that there shall be no liability on the therapist’s part should I fail to do so. I also understand that any illicit or
sexually suggestive behavior made by me will result in immediate termination of the session, and I will be
liable for payment of the scheduled appointment.
 The Massage Therapist shall not engage in breast massage of female clients without the written consent of
the client.
 Draping will be used during massage session agreed to by both client and therapist. Buttocks massage have
to be draped and massaged over the sheets.
 If client feel uncomfortable for any reason, the client may ask the therapist to cease the massage and
massage session will be ended.
Client Signature____________________________________________________Date_______________________
Practitioner Signature________________________________________________Date_______________________
Consent to Treatment of Minor: By my signature below, I hereby authorize______________________________
to administer massage, bodywork, or somatic therapy techniques to my child or dependent as they deem necessary.
Signature of Parent or Guardian________________________________________Date_______________________