New Client Intake - Christine Caprio, LMT

Please complete the following intake form.

Client Name:

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Today's Date

Month & year of birth

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Gender

Female

Male

Prefer not to answer

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Phone

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Referred by:

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Emergency Contact Name:

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Emergency Contact Phone:

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Have you ever received professional massage/bodywork before?

Yes

How recently?

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What types of massage/bodywork do you prefer?

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What kind of pressure do you prefer?

Light

Medium

Firm

What are your goals/expected outcomes for receiving massage/bodywork?

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List the medications you currently take:

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Do you wear any of the following?

Contacts

Dentures

Hairpiece

Other prosthetic

Select any of the following health conditions that you currently have (If you are unsure, please ask. Please answer honestly, as massage may not be indicated for the above conditions):

Blood clots

Infections

Congestive heart failure

Contagious diseases

Pitted edema

Diabetes

High or low blood pressure

Do you currently have or have a history of any of the following conditions?

Stroke and/or heart attack

Cancer

Neurological disorders (e.g. MS, Parkinson’s, chronic pain)

Epilepsy, seizures

Kidney disease, infection

Endocrine/thyroid conditions

Headaches, Migraines

Arthritis

Osteoporosis, degenerative spine/disk

Scoliosis

Allergies

Dizzy or lightheadedness

Memory loss, confusion, easily overwhelmed

Sensitive to touch or pressure

Varicose veins

Broken bones

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Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly.

Please check this box to continue.