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New Client Intake Form
Name
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Date of birth
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Address
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Phone number
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Email
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Occupation
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Emergency Contact: Name and Phone#
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Referred by...
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Have you had a professional massage before?
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required
Yes
No
What type of massage and what pressure do you prefer?
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required
Relaxation
Therapeutic
Light or Medium
Medium
Deep or Firm
Other
What are your goals for this session? ie. pain relief, stress relief, relaxation.
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Do you have any areas of discomfort in the body? Tension, Decreased Range of Motion, Stiffness, or pain. Rate pain level 1-10
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required
1
2
3
4
5
6
7
8
9
10
What makes it better or worse?
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Do you suffer from chronic pain?
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If yes, please explain. What makes it better? What makes it worse?
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Have you had surgery in the last year?
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If yes, please explain when and what area.
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Are you taking any medications or supplements?
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Yes
No
Please list name and use:
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Are you currently pregnant?
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required
Yes
No
Not applicable
If so, for how long? Any high risk factors?
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Please indicate any condition that you currently have or have had in the past.
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required
Cancer or Tumors
Diabetes
High or Low Blood Pressure
Heart Condition
Stent or Shunt or Pacemaker
Stroke
Headaches/Migraines
Fibromyalgia
Arthritis
Joint Replacements
Orthopedic injuries(dislocations
fractures
breaks
hernia
impingement
overuse)
Scoliosis or Osteoporosis
Lumbar or Herniated Disk or Spinal problems
Low back or Hip or Sciatica
Neck or Shoulder or Arm Pain
Sprains or Strains
Kidney Dysfunction
Blood Clots DVT
Lymphedema or Swelling
Neuropathy or Numbness or Tingling
Open sores or Rashes or Contagious skin disorders
Skin Disorders
Varicose Veins
Implants (breast
calves
pectoral
facial
glutes within the last 9 months)
Infectious Disease (viral
bacterial or fungal infections)
Fever or Cold or Flu
Digestive issues(IBS
Crohn's disease)
Other
Please explain any conditions you have marked above
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Do you have any requests or anything else I need to know? ie. sensitive to fragrances, allergies or areas to avoid.(feet, face, abdomen, etc.)
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Do you have any areas that you want specific work or extra time on?
*
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Is it ok for me to work on your hips?
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required
Yes
No
I have listed all my known medical conditions and physical limitations to the best of my knowledge and I will inform my therapist of any changes in my physical health.
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required
Yes
No
I agree to communicate any time I feel like my well-being is being compromised.
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required
Yes
No
I understand and agree: 1) the bodywork I am receiving is for the purposes of pain relief, stress reduction, relaxation, improving circulation and/or relief from muscle tension;
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required
Yes
No
2) the therapist neither diagnoses illness, disease or any other medical, physical or mental disorder, nor performs any spinal manipulations;
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required
Yes
No
3) I am responsible for consulting a qualified physician for any ailment I may have.
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required
Yes
No
I understand that all services rendered are my personal responsibility and payment is due at the time of service unless prior arrangements have been made.
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required
Yes
No
Please note that a 24-hour cancellation is required or a fee will be charged.
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required
Yes
No