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Consent Forms

Massage for the Entire Family. In-Home Healthcare and Group Classes.

Available Courses

Pediatric Medical Information

Pediatric Client Intake Form

Child’s Name __________________________________ Birthdate ______________ Age ________

Parent(s) Name(s) ____________________________ Home Phone ________________________

Work Phone ________________________ Cell Phone __________________________________

Street ___________________________ City__________________ State _______ Zip _________

Parent Occupation/Employer ________________________________________________________

Please mark your goals for your child’s Pediatric Massage Program:

Provide Comfort

Improve pulmonary functions

Promote relaxation

Decrease symptoms of atopic dermatitis

Reduce stress

Reduce lethargy

Reduce pain

Reduce colic / chronic abdominal pain

Ease Depression

Promote growth for baby born prematurely/child

Decrease anxiety

Improve self-soothing behavior

Reduce muscle hyper tonicity

Improve attentiveness and responsiveness

Improve muscle tone (decrease hypo tonicity)

Improve sleep patterns

Improve gastrointestinal functioning

Decrease hypersensitivity to touch

Improve joint mobility / range of motion

Encourage vocalization

Promote orientation of extremities toward midline

Enhance child’s body awareness

Reduce chronic fatigue

Promote parent-child bonding

Other Goals: ______________________________________________________________________

Health History

Birth History:  Biological Child  Adopted  Foster Child

Weeks gestation: _________ Delivery:  Vaginal Forceps  C-Section  Vacuum Extraction

Postpartum complications?  No  Yes (describe): _____________________________________

Is your child currently under the care of a primary healthcare provider?  Yes  No

Name of healthcare provider:__________________________________________________________

Name of healthcare facility: ___________________________________________________________

Location: ____________________________________________ Phone: ______________________

May I exchange information when necessary with this provider?  Yes  No

My child is developing:

 like an average child for his/her age in all areas of development

 differently than an average child his/her age in any area of development.

Describe: ________________________________________________________________________

Please list medications, supplements or homeopathics the child is now taking:


Please mark any of the following that your child now has or has had in the past. Identify the condition and location where applicable.







Skin Conditions

(includes rashes, topical allergies, fungal infections, etc.)

Type ______________________

Location ____________________

Respiratory Conditions

(includes sinus, lung and bronchial conditions, etc.)

Type ______________________

Location ____________________

Muscle Conditions

(includes strains, tendonitis, spasms, cramps)

Type ______________________

Location ____________________

Circulatory Conditions

(includes heart, blood pressure, arteries and venous conditions, etc.)

Type ______________________

Location ____________________

Joint Conditions

(includes sprain, arthritis, degenerating joints)

Type ______________________

Location ____________________

Reproductive Conditions

(includes pregnancy, prostate, menstruation)

Type ______________________

Location ____________________

Nervous System Conditions

(includes numbness, tingling, nerve damage, shingles, etc.)

Type ______________________

Location ____________________

Digestive Conditions

(includes constipation, diarrhea, ulcers)

Type ______________________

Location ____________________

Infectious or Communicable Conditions

Type ______________________

Location ____________________

Other Conditions

(includes any other health condition not previously listed)

Type ______________________

Location ____________________

Other medical conditions, symptoms and/or further explanations: ____________________________


Please list any recent accidents, illnesses or surgeries (past 2 years -- or those that are still affecting your child): ________________________________________________________________________________


Please list any special dietary/nutritional considerations: (ie: gluten-free diet, allergies)


How do these symptoms affect the child’s daily life? _________________________________________________________________________________

Therapeutic History

Has you child ever received massage or another bodywork therapy (professionally or by a parent’s touch)? (example: yoga therapy, cranial sacral therapy, bioaquatic therapy)  Yes  No

If yes, please explain: _________________________________________________________________________________


Please list other complementary therapies or educational programs in which your child participates:


May I exchange information when necessary with these providers?  Yes  No

Has your child been evaluated for or diagnosed with Sensory Integration Disorder?  Yes  No

If yes, please explain evaluation, diagnosis and/or therapy program: 






In the past

This is a problem

dislike being held or cuddled?

seem irritated when touched?

bang or hit head on purpose?

seem overly aware of touch, texture or temperature?

have an increased response to pain?

Lack awareness of being touched?

bite, chew or suck on blanket/pacifier/something to calm?

frequently bump into or push people or items?

have a strong need to touch objects and people?

try to bite people?

dislike being bounced, rocked or swung?

seek out rough-housing play?

have fear in space (i.e. on stairs, heights, etc.)?

dislike being off balance?

How does your child respond to touch/movement? Does your child:

Personal History

Please describe your child’s communication style:

 Verbal  Word Approximations  ASL  PECS  Augmentative Device  Gestures  None

Other: ________________________________________________________________________________

How does your child deal with change? ________________________________________________________________________________

What types of methods does your child use to manage stressful situations (self-soothing techniques)?



What makes your child: (And, how do you deal with it)






Does your child attend school/preschool/daycare?  Yes  No

If yes, what are his/her teacher’s name(s)? _____________________________________________

What are the names/types of his/her pets? ______________________________________________

What are the names of his/her siblings? _________________________________________________

What are the names of his/her friends? _________________________________________________

What types of exercise interests your child? _____________________________________________

How does your child prefer to spend his/her time (hobbies/interests)? _________________________


I have listed all my child’s known medical conditions and physical limitations and will inform the massage therapist in writing of any changes between bodywork sessions. I understand that a massage therapist must be aware of any and all existing physical conditions that my child has in order to provide appropriate massage. I further understand that a massage therapist neither diagnoses nor prescribes for illness, disease, or any other medical, physical, or emotional disorder, nor performs any thrusting joint or spinal manipulations or adjustments. I am responsible for consulting a qualified primary care provider for any physical ailment that my child may have.

I agree I will give twenty-four (24) hours notice to cancel any bodywork session to avoid being charged.

Signed ________________________________________________ Date ____________________

Parent/Legal Guardian of ___________________________________________________________