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First and last name*
Mobile number*
Email address
Address
Apartment, suite or unit number
City
State
Postal code
Additional Notes*
Date sent
Client Name:
Date:
Preferred phone number:
Best time to call:
Email address:
Preferred form of communication:
How did you hear about me? (referral, Facebook, etc.)
Is this a gift certificate?
Yes
No
Have you had a massage/bodywork before?*
Yes
No
Frequency:
Types of massage/bodywork received:
Preferred types of massage:
Reasons for seeking massage? (relaxation, injury, etc.)
Description of injury/health condition:
Possible complications/medications:
Expected outcomes (functional improvement, symptom relief, wellness):
Typical activities of daily living (affected by condition?):
Occupation (affected by condition?):
Best times for massage:
Communication Checklist (Pt. 1)*
Fees/forms of payment
Cancellation/No-show policy
Late arrival policy
Confidentiality
Communication Checklist (Pt. 2)*
Parking/directions
Work setting
Clothing/shiatsu
Communication Checklist (Pt. 3)*
Modesty/Nonsexual/draping
Food/drugs/alcohol
Oils/lotions/allergies
Do you have special needs I should prepare for:*
Have you had a fever in the last 24 hours of 100°F or above?
Yes
No
Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath
Yes
No
Do you now, or have you recently had, any chills, muscle aches, new loss of taste or smell, or new rashes or lesions?
Yes
No
Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms?
Yes
No
Do you have any questions or concerns:
If out-call, ask for directions, parking, or special instructions:
Packet Checklist*
Health Information
Health Status Report
Billing Information
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