Client Intake Form

Client Intake Form

Name ______________________________________ Phone (

) ____________________ DOB ______________________

Address ________________________________________________ City ________________ State ________ Zip __________

E-mail: ____________________________________________________________________________________________________

Referred by: ________________________________________________________Phone (

)__________________________

In case of emergency: ______________________________________________ Phone (

) __________________________

Occupation ________________________ K Male K Female

Physician____________________________________________

Health Insurance Carrier ____________________________________________________________________________________

Please take a moment to carefully read the following information and sign where indicated. If you have a specific

medical condition or specific symptoms, massage/bodywork may be contraindicated. A referral from your primary

care provider may be required prior to service being provided.

J Yes J No

Have you ever experienced a professional massage or bodywork session?

How recently?_________________

What are your massage or bodywork goals?______________________________________________________________________

J light

J medium

J firm

What kind of pressure do you prefer?

If you answer “yes” to any of the following questions, please explain as clearly as possible.

J Yes J No Do you frequently suffer from stress?

J Yes J No Do you bruise easily?

J Yes J No Do you have diabetes?

J Yes J No Any broken bones in the past two years?

J Yes J No Do you experience frequent headaches?

J Yes J No Any injuries in the past two years?

J Yes J No Are you pregnant?

J Yes J No Do you have tension or soreness in a specific area?

J Yes J No Do you suffer from arthritis?

Please specify ______________________________

J Yes J No Are you wearing contact lenses?

__________________________________________

J Yes J No Are you wearing dentures?

J Yes J No Do you have cardiac or circulatory problems?

J Yes J No Do you have high blood pressure?

J Yes J No Do you suffer from back pain?

J Yes J No Are you taking high blood pressure medication?

J Yes J No Do you have numbness or stabbing pains?

J Yes J No Do you suffer from epilepsy or seizures?

J Yes J No Are you sensitive to touch or pressure in any area?

J Yes J No Do you suffer from joint swelling?

J Yes J No Have you ever had surgery? Explain below.

J Yes J No Do you have varicose veins?

J Yes J No Other medical condition, or are you taking any

J Yes J No Do you have any contagious diseases?

medications I should know about?

J Yes J No Do you have osteoporosis?

Comments ______________________________________________

J Yes J No Do you have any allergies?

________________________________________________________

I understand that the massage/bodywork I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately

inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage or bodywork should not be construed as a substitute for medical examina-

tion, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage/bodywork

practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as

such. Because massage/ bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep

the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I also understand that any illicit or sexually sugges-

tive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment.

Client Signature ________________________________________ Date ______________________________________

Practitioner Signature __________________________________ Date ______________________________________

Consent to Treatment of Minor: By my signature below, I hereby authorize ______________________________________ to administer massage, bodywork, or

somatic therapy techniques to my child or dependent as they deem necessary.

Signature of Parent or Guardian ________________________________________________________________________ Date ____________________