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New Client Health Intake Form

Client Name:

Please fill out this field.

Date:

Date of Birth:

Gender:

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Phone:

Please enter a phone number.

Referred by:

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Emergency Contact Name:

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Emergency Contact Phone:

Please enter a phone number.

Physician/Health-care Provider Name:

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Physician/Health-care Provider Phone:

Please enter a phone number.

Have you ever received professional massage/bodywork before?

Yes

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 and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):

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Are you pregnant?

Yes

Have you had any injuries or surgeries in the past that may influence today’s treatment?

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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

None

Please fill out this field.