Master Client Intake Form

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Is this massage/bodywork medically necessary (is it for a medical condition, injury, surgery)? required
Do you have a physician referral/prescription? required
Are you seeking insurance reimbursement (If yes, please complete the Billing Information form)? required
Type of insurance coverage for this claim:
Have you ever received professional massage/bodywork before? required
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What kind of pressure do you prefer? required
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Do these symptoms interfere with your activities of daily living ( e.g., sleep, exercise, work, childcare)? required
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Are you wearing contacts? required
Are you wearing dentures? required
Are you wearing a hairpiece? required
Are you pregnant? required
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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): required
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Muscle or joint pain required
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Muscle or joint stiffness required
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Numbness or tingling required
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Swelling required
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Bruise easily required
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Sensitive to touch/pressure required
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: High/Low blood pressure required
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Stroke, heart attack required
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Varicose veins required
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Shortness of breath, asthma required
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Cancer required
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) required
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Epilepsy, seizures required
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Headaches, Migraines required
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Dizziness, ringing in the ears required
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) required
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Gas, bloating, constipation required
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Kidney disease, infection required
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Arthritis (rheumatoid, osteoarthritis) required
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Osteoporosis, degenerative spine/disk required
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Scoliosis required
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Broken bones required
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Allergies required
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Diabetes required
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Endocrine/thyroid conditions required
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Depression, anxiety required
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Memory Loss, confusion, easily overwhelmed required
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Symptom 1 Location
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Sympton 1:
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Symptom 2 Location
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Symptom 2:
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Symptom 3 Location
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Symptom 3:
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Have you had a fever in the last 24 hours of 100°F or above? required
Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath? required
Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms? required
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