New Client Intake Form
Date:
Client Name:*
Date of Birth:*
Address:
Phone:*
Email:*
Referred by:
Have you had any injuries or surgeries in the past that may influence bodywork treatment?
Do these symptoms interfere with your daily living activities? ( e.g., sleep, exercise, work, childcare)?
Yes
No
How would you rate your overall health?
Excellent
Good
Fair
Poor
List current medications and the conditions they're treating*
Are you wearing contacts?
Yes
No
Are you wearing dentures?
Yes
No
Do you bruise easily? *
Yes
No
Are you pregnant?*
Yes
No
If yes, how far along are you?
Is your pregnancy high risk?
Please list any allergies or hypersensitives:
Have you ever received professional massage/bodywork before?
Yes
No
What types of massage/bodywork do you prefer?
What kind of pressure do you prefer?
Light
Medium
Firm
Is this massage/bodywork medically necessary (is it for a medical condition, injury, surgery)?
Yes
No
What are your goals/expected outcomes for receiving massage/bodywork?*
Scalp
Pectoral muscles "pecs"
Abdomen
Gluteal muscles "glutes"
Feet
Head/Neck:*
Headaches /Migraines
Ringing in ear
Vision problems
Vertigo /Dizziness
Hearing loss
N/A
Respiratory: *
Asthma
Chronic cough
Emphysema
Shortness of breath
Bronchitis
Sinusitis
N/A
Musculoskeletal System: *
Arthritis
Osteoporosis
Bursitis
Pins/Plates/Wires//Artificial plants
Tendonitis
TMJ
N/A
Cardiovascular: *
High blood pressure
Heart attack
Heart disease
Phlebitis /Varicose veins
Low blood pressure
Poor circulation
Pace maker
Stroke
N/A
Nervous System: *
Sensory loss
Sciatica
Seizures
Numbness /Tingling
Epilepsy
N/A
Skin Infections:*
Hepatitis
Herpes
Lyme disease
HIV/AIDS
Infectious skin conditions
Tuberculosis
N/A
Other conditions:*
Cancer
Fibromyalgia
Depression
Anxiety
Psychiatric disorder
Diabetes
Digestive conditions
Chronic fatigue syndrome
N/A
Any other condition your practitioner should be aware of ?*
I understand that no inappropriate comments or conduct will be tolerated. Any indication of such will terminate the session and result in a full charge of the service. (Sign name below)*
I understand that my personal health information will be collected. I understand that all information that I provide will be kept confidential unless required by law. (Sign name below)*
I acknowledge that massage therapy is not a substitute for medical care, medical examination, or diagnosis. (Sign name below) *
Write your full name below for signature*
Emergency Contact Name:
Emergency Contact Phone:
Comments:
Please list your favorite genre of music you enjoy for relaxation