Master Client Intake Form
Is this massage/bodywork medically necessary (is it for a medical condition, injury, surgery)?*
Do you have a physician referral/prescription?*
Are you seeking insurance reimbursement (If yes, please complete the Billing Information form)?*
Type of insurance coverage for this claim:
Have you ever received professional massage/bodywork before?*
What kind of pressure do you prefer?*
Do these symptoms interfere with your activities of daily living ( e.g., sleep, exercise, work, childcare)?*
List the medications you currently take:*
Are you wearing contacts?*
Are you wearing dentures?*
Are you wearing a hairpiece?*
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):*
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Muscle or joint pain*
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Muscle or joint stiffness*
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Numbness or tingling*
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Swelling*
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Bruise easily*
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Sensitive to touch/pressure*
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: High/Low blood pressure*
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Stroke, heart attack*
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Varicose veins*
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Shortness of breath, asthma*
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Cancer*
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)*
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Epilepsy, seizures*
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Headaches, Migraines*
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Dizziness, ringing in the ears*
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)*
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Gas, bloating, constipation*
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Kidney disease, infection*
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Arthritis (rheumatoid, osteoarthritis)*
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Osteoporosis, degenerative spine/disk*
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Scoliosis*
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Broken bones*
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Allergies*
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Diabetes*
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Endocrine/thyroid conditions*
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Depression, anxiety*
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Memory Loss, confusion, easily overwhelmed*
Is there anything else I should know about how you are feeling today or about your progress or care to date?
Have you had a fever in the last 24 hours of 100°F or above?*
Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath?*
Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms?*