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New Client Health Intake Form

All you have to fill out is:
Clients name
Birthday
Address
Phone number
At the bottom your name for signature
Today's date

Anything else would be helpful, but if you don't want to fill it out. I don't want to force you. Forms are not relaxing.

Client Name:

Please fill out this field.

Date of Birth:

Address:

Please fill out this field.

Phone:

Please enter a phone number.

Email:

Please enter a valid email address.

Emergency Contact Name:

Please fill out this field.

Emergency Contact Phone:

Please enter a phone number.

Have you ever received professional massage/bodywork before?

Yes

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

Please fill out this field.

How do you feel today?

Please fill out this field.

If yes, explain

Please fill out this field.

Are you wearing dentures?

Yes

Are you pregnant?

Yes

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

Please fill out this field.

Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Swelling

Current

Past

Not Applicable

Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Arthritis (rheumatoid, osteoarthritis)

Current

Past

Not Applicable

Please fill out this field.

Write your full name below for signature

Please fill out this field.

Enter today's date

Please fill out this field.

Write your full name below for signature (in case of a minor)

Please fill out this field.

Enter today's date (in case of a minor)

Please fill out this field.