New Client Health Intake Form
Is this massage/bodywork medically necessary (is it for a medical condition, injury, surgery)?
Have you ever received professional massage/bodywork before?
What kind of pressure do you prefer?
Do these symptoms interfere with your activities of daily living ( e.g., sleep, exercise, work, childcare)?
List the medications you currently take:
Are you wearing contacts?
Are you wearing dentures?
Are you wearing a hairpiece?
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):
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Muscle or joint pain
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Muscle or joint stiffness
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Numbness or tingling
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Swelling
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Bruise easily
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Sensitive to touch/pressure
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: High/Low blood pressure
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Stroke, heart attack
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Varicose veins
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Shortness of breath, asthma
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Cancer
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Neurological (e.g. MS, Parkinson’s, chronic pain)
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Epilepsy, seizures
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Headaches, Migraines
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Dizziness, ringing in the ears
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Digestive conditions (e.g. Crohn’s, IBS)
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Gas, bloating, constipation
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Kidney disease, infection
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Arthritis (rheumatoid, osteoarthritis)
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Osteoporosis, degenerative spine/disk
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Scoliosis
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Broken bones
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Allergies
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Diabetes
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Endocrine/thyroid conditions
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Depression, anxiety
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Memory Loss, confusion, easily overwhelmed