Client Health Intake Form - Massage - Fairfax Station Chiropractic printable pdf download

Client Health Intake Form – Massage

Name:________________________________________________________ Date of Birth:______________________

Last

First

Address:_________________________________________________ Phone: (cell, home, work) _________________

Circle one

City/State/Zip:____________________________________________ Phone: (cell, home, work) _________________

Circle one

Email:_________________________________________ Occupation/Employer:______________________________

Emergency Contact:______________________________ Relationship:________________ Phone:_______________

1. Have you ever had a professional massage? ☐ Yes ☐ No

If yes, how often do you receive massages? _____________________________________________________

2. What do you hope to achieve from today’s massage? __________________________________________________

3. Please circle the type of pressure you prefer for your massage:

light

medium

deep

4. Please circle any areas of your body where you prefer NOT to receive massage:

head

face

neck

arms

chest

abdomen

back

buttocks

legs

feet

other _______________

5. Is there a particular area where you are experiencing tension, stiffness, pain, or other discomfort? ☐ Yes ☐ No

If yes, please identify: _______________________________________________________________________

6. Do you have any chronic (ongoing) pain? ☐ Yes ☐ No

If yes, please explain: _______________________________________________________________________

What activities cause the pain and/or make it worse? _____________________________________________

7. Are you currently under the care of a healthcare practitioner? ☐ Yes ☐ No

If yes, please explain: _______________________________________________________________________

8. Are you currently taking any medications, herbs, or supplements? ☐ Yes ☐ No

If yes, please list: __________________________________________________________________________

9. Please describe your previous history (include year & treatment received):

Surgeries: ________________________________________________________________________________

Hospitalizations: ___________________________________________________________________________

Accidents: ________________________________________________________________________________

Client Health Intake Form - Massage - Fairfax Station Chiropractic