New Client Intake Form
Please complete the New Client Intake Form prior to the start of your appointment. This will help me get a better idea of what issues you're experiencing and will help me to determine a path for our treatment plan. I can't wait to start working with you! See you soon!
Contact Information:
Client Name:*
Date of Birth:
Gender:
Preferred pronouns (if any):
Address:
Phone:*
Email:
Referred by:
Emergency Contact Name:
Emergency Contact Phone:
Physician/Health-care Provider Name and Phone Number:
Is this massage/bodywork medically necessary (is it for a medical condition, injury, surgery)?
Yes
No
Do you have a physician referral/prescription?
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
Deep
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
If yes, explain
List the medications you currently take:
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 answer the following questions and indicate conditions that you have or have had in the past. Muscle or joint pain
Current
Past
Not Applicable
Muscle or joint stiffness
Current
Past
Not Applicable
Numbness or tingling
Current
Past
Not Applicable
Swelling
Current
Past
Not Applicable
Bruise easily
Current
Past
Not Applicable
Sensitive to touch/pressure
Current
Past
Not Applicable
High/Low blood pressure
Current
Past
Not Applicable
Stroke, heart attack
Current
Past
Not Applicable
Varicose veins
Current
Past
Not Applicable
Shortness of breath, asthma
Current
Past
Not Applicable
Cancer
Current
Past
Not Applicable
Neurological (e.g. MS, Parkinson’s, chronic pain)
Current
Past
Not Applicable
Epilepsy, seizures
Current
Past
Not Applicable
Headaches, Migraines
Current
Past
Not Applicable
Dizziness, ringing in the ears
Current
Past
Not Applicable
Digestive conditions (e.g. Crohn’s, IBS), bloating, constipation
Current
Past
Not Applicable
Kidney disease, infection
Current
Past
Not Applicable
Arthritis (rheumatoid, osteoarthritis)
Current
Past
Not Applicable
Osteoporosis, degenerative spine/disk
Current
Past
Not Applicable
Scoliosis
Current
Past
Not Applicable
Broken bones
Current
Past
Not Applicable
Allergies
Current
Past
Not Applicable
Diabetes
Current
Past
Not Applicable
Endocrine/thyroid conditions
Current
Past
Not Applicable
Depression, anxiety
Current
Past
Not Applicable
Memory Loss, confusion, easily overwhelmed
Current
Past
Not Applicable
Please use this box to elaborate further on any issues or conditions you may have that you feel is relevant information to your bodywork session:
I acknowledge that I have reviewed the Cancellation Policy outlined in the FAQ section of the website and will adhere to said policy outlined by the company, Good Vibes Bodywork.*
Check the box if true
I acknowledge that I have reviewed the Sickness/Emergency/Weather Policy outlined in the FAQ section of the website and will adhere to said policy outlined by the company, Good Vibes Bodywork.*
Check the box if true
I acknowledge that I have reviewed the Payment/Insurance Policy outlined in the FAQ section of the website and will adhere to said policy outlined by the company, Good Vibes Bodywork.*
Check the box if true
I acknowledge that I have reviewed the Inappropriate Behavior Policy outlined in the FAQ section of the website and will adhere to said policy outlined by the company, Good Vibes Bodywork.*
Check the box if true
Write your full name below for signature*
Enter today's date*