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:*
Date of Birth:*
Address:*
Phone:*
Email:
Emergency Contact Name:
Emergency Contact Phone:
Have you ever received professional massage/bodywork before?
Yes
No
What are your goals/expected outcomes for receiving massage/bodywork?
How do you feel today?
If yes, explain
Are you wearing dentures?
Yes
No
Are you pregnant?
Yes
No
Have you had any injuries or surgeries in the past that may influence today’s treatment?
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
Comments: any surgeries, illnesses, diseases or anything else I should know
Write your full name below for signature*
Enter today's date*
Write your full name below for signature (in case of a minor)
Enter today's date (in case of a minor)