Massage/reiki Client Intake Form printable pdf download

Massage/reiki Client Intake Form

Massage/Reiki Client Intake Form

Name: _________________________________________ Date: __________________

Address: _______________________________________________________________

City: ________________________________ State: ________ Zip: ________________

Email: ________________________________________________

Home Phone: __________________________ Cell Phone: ______________________

Emergency Contact: ____________________________ Phone: __________________

Are you taking any medication? Yes / No (Please list)

Are you under the care of a medical practitioner? Yes / No

Have you ever had a Massage or Reiki treatment? Yes / No

Do you have a particular area of concern?

Are you sensitive to perfumes or fragrances? Yes / No

Are you sensitive to touch? Yes / No

If you have had any recent or chronic medical conditions, please check them below:

____ Blood Clotting Disorder

____ Recent Surgery

____ Respiratory

____ Circulatory/Heart

____ Herniated Disks

____ Digestive

____ Ulcers

____ Varicose Veins

____ Arthritis

____ Diabetes

____ Anemia

____ Allergies

____ Fractures /Bone Trauma

____ Headaches

____ Nausea

____ Fainting or Dizzy Spells

____ Car Accidents

____ Epilepsy

____ Muscle Cramping

____ Wear Contacts

____ Allergies to Essences/Oils

____ Jaw Pain or Injury

____ Neurological Problems

____ Malignant Condition/Cancer

____ High Blood Pressure

____ Dislocations, Strains, Sprains

____ TB/Communicable Disease -____ Back/Neck Discomfort/Injuries

Massage/reiki Client Intake Form