Massage by Valerie Scarberry

An unforgettable touch...

This form must be filled out prior to your first massage. I will bring a copy with me for you to fill out if you would like to save time you may print this page and fill it out.

Intake Form




NAME ___________________________                         

DATE OF BIRTH __________________ 


ADDRESS ___________________________________                   

OCCUPATION ____________________


CITY/ZIP ___________________________                                    

REFERRED BY ____________________


PHONE (H) ________________ (W) _______________                

EMAIL ___________________________


EMERGENCY CONTACT __________________________

EMERGENCY  # _______________________________


If you are pregnant we need to do an evaluation to determine if you

are eligible for massage at this time.

If you have taken narcotic pain medication or muscle relaxants within

the past 12 hours, you must consult with me prior to massage.


Is this your first massage?  Y             N           

Physical Activities __________________________

What results would you like from your massage:

Decrease muscle stiffness                    Increase mobility   

General wellness    Decrease pain/pain management

Other specific physical and/or emotional concerns


Specify and prioritize problem areas to be focuses on _______________________________________

Any body part you do not want worked on _______________________________________


How would you rate your current state of health? 

Excellent           Good       Fair         Poor

Are you currently under care of a physician?   Y             N

If so, for what reason? ____________________________________________________________________

Are you currently taking ANY Medications (please include all)

Y              N   If so, what medications and for what reasons,  _____________________________________________


List Allergies


List any Surgeries

Accidents? <5 yrs ago _____________________________             

                 >5 yrs ago ________________________
What happened in the above accidents _____________________________________________________

Are there any other current or previous health conditions that may be affecting your health or functioning?

Y              N        If yes, please explain, _____________________________________________________________


IMPORTANT Please indicate if you have any of the following conditions, because, if so, standard massage techniques may not be appropriate.

High blood pressure   Osteoporosis    Swelling/ Edema              

Diabetes     Recent injury    Chronic Pain Treatment 

Fever/Acute infection    Undiagnosed Acute Pain    

HIV/AIDS/Hepatitis/Infectious Disease    Cancer     Stroke

Disease of the heart or blood vessels  Kidney Disease  

Disease of the Nervous System   Gastrointestinal or Liver Disease


I understand that a massage therapist does not diagnose, prescribe or treat any specific conditions. I understand that massage therapy is not a substitute for medical examination, diagnosis, and treatment. It is recommended that I see a physician for any ailment I might have. I will update my therapist before any massage if there is change in my medical history. I consent to receive a massage.



Signature __________________________________________      

Date ________________________________________



Please use the space below for any additional information.