New Client Health Intake Form
Enter today's date*
Client Name:*
Address:
Phone:
Email:*
Gender:
Date of Birth:*
Referred by:
Emergency Contact Name:*
Emergency Contact Phone:*
Contact Information:
Are you wearing contacts?
Yes
No
Are you wearing dentures?
Yes
No
How do you feel today?
Practitioner/Clinic :
Are you pregnant?
Yes
No
Do you have a physician referral/prescription?
Yes
No
Physician/Health-care Provider Name:
Physician/Health-care Provider Phone:
Have you ever received professional massage/bodywork before?
Yes
No
List the medications you currently take:
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?
How recently?
Do these symptoms interfere with your activities of daily living ( e.g., sleep, exercise, work, childcare)?
Yes
No
If yes, explain
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
Comments:
List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):
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
No
What are your goals/expected outcomes for receiving massage/bodywork?
Write your full name below for signature