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New Client Health Intake Form

Enter today's date

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Client Name:

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Address:

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Phone:

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Email:

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Gender:

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Date of Birth:

Referred by:

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Emergency Contact Name:

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Emergency Contact Phone:

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Contact Information:

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Are you wearing contacts?

Yes

Are you wearing dentures?

Yes

How do you feel today?

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Practitioner/Clinic :

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Are you pregnant?

Yes

Do you have a physician referral/prescription?

Yes

Physician/Health-care Provider Name:

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Physician/Health-care Provider Phone:

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Have you ever received professional massage/bodywork before?

Yes

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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: 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: High/Low blood pressure

Current

Past

Not Applicable

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

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How recently?

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Do these symptoms interfere with your activities of daily living ( e.g., sleep, exercise, work, childcare)?

Yes

If yes, explain

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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: Varicose veins

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: 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: 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: 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: Cancer

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: Bruise easily

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: 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: 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: Epilepsy, seizures

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: Headaches, Migraines

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: Memory Loss, confusion, easily overwhelmed

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: Broken bones

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: 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

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List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):

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What kind of pressure do you prefer?

Light

Medium

Firm

Is this massage/bodywork medically necessary (is it for a medical condition, injury, surgery)?

Yes

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

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Write your full name below for signature

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