Client Intake Form
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1CLIENT INTAKE FORM
Name:_____________________________
Name:_____________________________
Name:_____________________________
Date of Birth:_______________
Date of Birth:_______________
Date of Birth:_______________
Today’s Date:_______________
Today’s Date:_______________
Today’s Date:_______________
Address: ___________________________
Address: ___________________________
Address: ___________________________
City:_____________________
City:_____________________
City:_____________________
State:________
State:________
State:________
Zip:_________
Zip:_________
Zip:_________
Primary Complaint:________________________________________________
_______________________________________________
_______________________________________________
Phone #:__________________
Phone #:__________________
Phone #:__________________
Please mark and label the diagram with aches, pains, numbness, or other problems.
Please mark and label the diagram with aches, pains, numbness, or other problems.
Please mark and label the diagram with aches, pains, numbness, or other problems.
X – Stabbing Pain
Stabbing Pain
O – Numbness
Numbness
//// - Aches
Aches
+++ - Pins and Needles
Pins and Needles
----Burning
Burning
Have you ever had a professional massage before? YES/NO
ever had a professional massage before? YES/NO
Are you under the care of any health care professional? YES/NO__________________________
Are you under the care of any health care professional? YES/NO__________________________
Are you under the care of any health care professional? YES/NO__________________________
Are you taking any medications? _________________________________________________
Are you taking any medications? _________________________________________________
Are you taking any medications? _________________________________________________
If you have any recent or chronic medical conditions, please check them below and discuss them with your
dical conditions, please check them below and discuss them with your
dical conditions, please check them below and discuss them with your
massage therapist.
Have you had or do you have any of the following:
Have you had or do you have any of the following:
___ jaw pain/injury
___Back discomfort or injury
___neck discomfort
___neck discomfort
___headaches
___high blood pressure
___circulatory/heart problems
irculatory/heart problems
___anemia
___varicose veins
___blood clotting disorder
___blood clotting disorder
___epilepsy
___malignant condition or cancer
___muscle cramping
muscle cramping
___respiratory problems
___fainting spells or dizziness
___ulcers
___ulcers
___digestive problems
___neurological problems
___diabetes
___diabetes
___numbness/tingling
___recent surgery (explain on back) ___TB
___herniated disks
___allergies (__to essences __to oils)___dentures
___allergies (__to essences __to oils)___dentures
___fractures/bone trauma
___fractures/bone trauma
___dislocations/sprains/strains
___arthritis
___arthritis
___currently pregnant
___alcohol in the last 3 hours
___contact lenses
___contact lenses
___car accidents
___fibromyalgia
___chronic fatigue
___chronic fatigue
Do you have any other medical condition that your practitioner should be aware of before performing your
Do you have any other medical condition that your practitioner should be aware of before performing your
Do you have any other medical condition that your practitioner should be aware of before performing your
massage?__________________________
massage?__________________________________________________
Please read before signing:
I understand that the purpose of this massage is for stres
I understand that the purpose of this massage is for stress reduction, relief from muscular tension or spasm, or for increasing
rom muscular tension or spasm, or for increasing
circulation. I understand that the massage therapist does not diagnose
circulation. I understand that the massage therapist does not diagnose illness, disease, or any other physical or mental disorder. As
illness, disease, or any other physical or mental disorder. As
such, the massage therapist does not prescribe medical treatment or pharmaceuticals. This massage session is not a substitut
such, the massage therapist does not prescribe medical treatment or pharmaceuticals. This massage session is not a substitut
such, the massage therapist does not prescribe medical treatment or pharmaceuticals. This massage session is not a substitute for
medical examinations and/or diagnosis. It is recommended that
medical examinations and/or diagnosis. It is recommended that I see a physician for any physical ailment
that I have. I understand that
massage therapists need to be aware of existing physical
massage therapists need to be aware of existing physical conditions; therefore, I have stated all of my known medical conditions and
therefore, I have stated all of my known medical conditions and
take it upon myself to keep the massage therapist updated on my physical health. I also understand that any illicit or sexually
st updated on my physical health. I also understand that any illicit or sexually
st updated on my physical health. I also understand that any illicit or sexually
suggestive behavior, remarks, or advances made by me will result in immediate termination of the session and I will be liable
suggestive behavior, remarks, or advances made by me will result in immediate termination of the session and I will be liable
suggestive behavior, 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
Signature:__________________________
______________
Date:________
____________________
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