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Client Health Intake Form
Client Name:
*
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Preferred Name:
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Birthday:
*
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Phone:
*
Please enter a phone number.
Email:
*
Please enter a valid email address.
Address:
*
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City:
*
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State:
*
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Zip code:
*
Please enter a number.
Occupation:
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What are your goals/expected outcomes for receiving massage/bodywork?
*
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List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):
Please fill out this field.
How do you feel today?
*
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Do these symptoms interfere with your activities of daily living ( e.g., sleep, exercise, work, childcare)?
Yes
No
Sometimes
If yes, explain
Please fill out this field.
List the medications you currently take:
*
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Have you had any injuries or surgeries?
*
Please fill out this field.
Are you pregnant (yes, no, unsure) and how far along?
Please fill out this field.
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 following conditions):
*
required
Blood clots
Infections
Congestive heart failure
Contagious diseases
Pitted edema
None of the above
Please indicate if you are experiencing or have had any of the following
*
required
Numbness or tingling
Swelling
Bruise easily
Sensitive to touch/pressure
Hi/low blood pressure
Stroke or heart attack
Varicose veins
Shortness of breath or asthma
Cancer, any stage
Neurological issues, e.g. MS, Parkinson’s, chronic pain
Epilepsy or seizures
Dizziness or ringing in the ears
Digestive conditions, e.g. Crohn’s, IBS
Kidney disease or infection
Arthritis, e.g., rheumatoid, osteoarthritis
Diabetes
Endocrine/thyroid conditions
Depression or anxiety
None of the above
Please explain any of the above selected conditions:
Please fill out this field.
Do you have any allergies, including skin sensitivities?
*
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Please select the type of massage therapy services or techniques that you are anticipate receiving during the session.
*
required
Massage
Pregnancy Massage
Stone Massage
Massage with Cupping
Body Treatment
Relaxation Facial
Refelxology
AromaTouch
Which areas of your body do you consent to have treated during your session? Please check all areas you give permission to be worked on. Any unchecked areas will not be treated.
*
required
Scalp
Face
Neck and décolleté (collarbone area)
Shoulders
Arms/Hands
Back
Hips/Glutes
Legs
Feet
Abdominal Area (the chest is covered and worked on by request)
Anything else you wish to share?
Please fill out this field.
Today's Date:
*
August 2026
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Please write your full name below for client/guardian signature
*
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