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RESToration Massage by Diana: Intake Form 1 of 2 Personal Information:
To help us serve your massage needs, please answer the questions honestly. Any information provided is confidential.
Name __________________________________ Best Contact Number ______________ Home Cell
Address ________________________________ City, State & Zip ________________________________________ Birth date _______________________________ Email _________________________________________________ 
How did you hear about us?
1. Have you had a professional massage before?
If yes, how often do you receive massage therapy?
2. What prevents you from getting a massage more often, if anything? 3. Do you have any difficulty lying on your front, back, or side?
4. Do you have any allergies to oils, lotions, or scents? If yes, please explain
5. What are your therapeutic goals for this massage session?
 6. Are you currently under a physician’s care?
If yes, physician’s name _______________________________ Contact # ( ) ___________
7. Are you currently taking any medications?
If yes, please list ___________________________________________________________________________
8. Please check any condition listed below that applies to you:
  contagious skin condition (Athletes foot, scabies etc) open sores or wounds recent fracture, strain, sprain or surgery recent surgery
artificial joint
current fever, swollen glands, infection/fever?
decreased sensation
back/neck injuries
fibromyalgia
TMJ
carpal tunnel syndrome or tennis elbow
pregnancy – How many weeks? _____ high risk requires doctor’s note atherosclerosis
heart condition
high or low blood pressure varicose veins phlebitis
deep vein thrombosis/blood clots joint disorders
osteoporosis
epilepsy
headaches/migraines
cancer: please elaborate: _________________________ diabetes, Is it controlled? plantar fasciitis arthritis Where? ___________________________ recent accident or injury (Include car accidents in the past and anything current- include dates)

Pressure type: Light Medium Deep
It is your responsibility to inform your therapist if the pressure is too much or too little. Please be aware that if taking any pain killer it will lessen your ability to feel, and may not be able to feel the amount of pressure being received.

POLICIES:. I UNDERSTAND EMERGENCIES HAPPEN AND I FULLY EXPECT YOU TO HANDLE YOUR BUSINESS AND PERSONAL LIFE ACCORDINGLY ( SICK KIDDO, FLAT TIRE, LAST MINUTE SICKNESS ETC); HOWEVER, PLEASE DON'T MAKE YOUR EMERGENCY, MY EMERGENCY AND PLEASE SEND A PAYMENT VIA VENMO, OR CHECK THE IN THE MAIL, OR A FORFEITURE OF A PRE PAID PACKAGE ( IT IS STILL MY POLICY). I OFFER A 30 MINUTE CREDIT WHEN I HAVE A LAST MINUTE OBLIGATION MYSELF, MOST BUSINESSES DO NOT DO THIS, BUT I ALSO WANT TO RESPECT YOUR TIME AS WELL. I AM EXTREMELY SYMPATHETIC FOR WHAT HAPPENS IN YOUR LIFE, BUT I STILL NEED TO PROVIDE FOR MY FAMILY AND PAY FOR ITEMS TO KEEP MY DOORS OPEN, AND I CAN'T DO THAT IF NO NOTICE IS PROVIDED. 12 HOURS IS THE BARE MINIMUM BUT IF ITS USED ALL THE TIME, I WILL REQUIRE 24 HOURS NOTICE. PLEASE NOTE, IT IS YOUR RESPONSIBILITY TO CHECK YOUR REMINDERS THAT ARE SENT AUTOMATICALLY, AND NOTE IT IS A COURTESY TO HAVE THEM. WE ARE ADULTS, PLEASE WRITE THEM DOWN. I agree to inform my therapist immediately if I experience pain. I certify that I have disclosed all known medical conditions and acknowledge that my therapist is not responsible for the aggravation of any unknown or undisclosed condition. I also acknowledge that this massage is therapeutic and that any inappropriate solicitation of my therapist will result in the immediate termination of my massage without refund. Disclaimers: Draping will be used during all sessions. Minors receiving a massage must be accompanied with a parent during the massage, and women deemed with a high-risk pregnancy needs a doctor’s note. Massage therapists are not qualified to perform spinal adjustments, diagnose, prescribe, or treat any physical or mental illness and nothing said during the session should be construed as such. Deep-tissue and trigger point may cause soreness. Clients are advised to remain hydrated, stretch and apply hot and cold packs as indicated and advised by your physician.

​ X______________________________________ Signature of Client/ Date