Elbow Room Massage Therapy
Client Intake Form
Alex Adamczyk, LMT · GA License #MT013193
Inside Stauffer Chiropractic
4595 Towne Lake Pkwy, Bldg 300, Ste 100
Woodstock, GA 30189
Date: ____________________

Client Information

Today's Visit

Yes No If yes, with whom:

Health History

No Yes, weeks: ______

Please check anything you have or have had

This helps us work safely. Checking a box does not always mean we cannot work, it just tells us where to take care.

Blood clots / DVT Heart condition High blood pressure Low blood pressure Stroke Diabetes Cancer (current or past) Osteoporosis Arthritis Fibromyalgia Numbness / tingling Varicose veins Recent fracture / injury Skin condition / rash Contagious condition

Areas of Focus

Front
Back

Mark the figures:

  • X = pain   O = tension / tightness   △ = please avoid
Light Medium Firm Deep

Massage History & Preferences

Yes No

Informed Consent

I understand that massage therapy is provided for relaxation, relief of muscular tension, and general well-being. The therapist does not diagnose illness or disease, does not prescribe, and massage is not a substitute for medical care. I have shared all relevant health information and will tell the therapist of any changes. I will stay draped except for the area being worked, and I understand I may adjust pressure, decline any technique, or stop the session at any time. I am voluntarily seeking massage from Elbow Room Massage Therapy and consent to treatment.
Your health information is kept confidential and used only to provide and coordinate your care.  •  Elbow Room is not accepting clients under 18 at this time.  •  elbowroommassage.com