New Client Health Intake/Consent Form
Date*
Client Name:*
Date of birth*
Gender:*
Address:*
Phone:*
Email:
Referred by:
Emergency Contact Name:
Emergency Contact Phone:
Is this massage/bodywork medically necessary (is it for a medical condition, injury, surgery)?
Yes
No
Have you ever received professional massage/bodywork before?*
Yes
No
How recently?
What types of massage/bodywork do you prefer?*
What kind of pressure do you prefer?*
Light
Medium
Firm
What are your goals/expected outcomes for receiving massage/bodywork?
How do you feel today?
List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):
Do these symptoms interfere with your activities of daily living ( e.g., sleep, exercise, work, childcare)?
Yes
No
sometimes, like when I (try to) do a certain movement
If yes, explain
List the medications you currently take:
Are you wearing contacts?*
Yes
No
Are you wearing dentures?
Yes
No
Are you wearing a hairpiece?*
Yes
No
Are you pregnant?*
Yes
No
Have you had any injuries or surgeries in the past that may influence today’s treatment?*
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
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Muscle or joint pain
Current
Past
Not Applicable
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Muscle or joint stiffness
Current
Past
Not Applicable
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Numbness or tingling
Current
Past
Not Applicable
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: Bruise easily
Current
Past
Not Applicable
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Sensitive to touch/pressure
Current
Past
Not Applicable
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: High/Low blood pressure
Current
Past
Not Applicable
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Stroke, heart attack
Current
Past
Not Applicable
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Varicose veins
Current
Past
Not Applicable
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Shortness of breath, asthma
Current
Past
Not Applicable
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Cancer
Current
Past
Not Applicable
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)
Current
Past
Not Applicable
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Epilepsy, seizures
Current
Past
Not Applicable
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Headaches, Migraines
Current
Past
Not Applicable
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Dizziness, ringing in the ears
Current
Past
Not Applicable
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)
Current
Past
Not Applicable
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Gas, bloating, constipation
Current
Past
Not Applicable
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Kidney disease, infection
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 indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Osteoporosis, degenerative spine/disk
Current
Past
Not Applicable
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Scoliosis
Current
Past
Not Applicable
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Broken bones
Current
Past
Not Applicable
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Allergies
Current
Past
Not Applicable
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Diabetes
Current
Past
Not Applicable
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Endocrine/thyroid conditions
Current
Past
Not Applicable
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Depression, anxiety
Current
Past
Not Applicable
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Memory Loss, confusion, easily overwhelmed
Current
Past
Not Applicable
Comments:
Write your full name below for signature*
Enter today's date*