Client Intake Form printable pdf download

Name: ________________________________________

Date: ____________________

Address: ________________________________________

Home Phone: ______________

City: _______________State: ______Zip: _________

Cell Phone: ________________

Occupation: ________________________________________

Work Phone: _______________

Date of Birth: ________________________________________

Email: ____________________

Referred by: ________________________________________

Emergency Contact: ________________________________________

E.C. Phone: ________________

Health / Medical History

Are you experiencing any of the following:

___ Depression/Anxiety

___ Numbness/Tingling

___ Cold/Flu

___ Muscular/Skeletal Disorders

___ Piercing or Stabbing Pain

___ Fever

___ New tattoos/piercings

___ Frequent Headaches

___ Infections

___ Digestive Disorders

___ Back Pain

___ Contagious Conditions

___ Possible or Definite Pregnancy

___ Arthritis

___ Burns/Sunburn

___ Joint Swelling

___ Other __________________

___ Skin Condtions (e.g. warts)

___Tendonitis

___ Cuts/Bruises

Have you ever been diagnosed with, or been advised to seek treatment for any of the following:

___ Osteoporosis

___ Varicose veins

___ High / Low Blood Pressure

___ Disc Disorders

___ Bruising easily

___ Stroke / TIAs

___ Neuritis / Nerve Disorders

___ Lymphatic Conditions

___ Diabetes / Low Blood Sugar

___ Seizure Disorders / Epilepsy

___ Kidney / Bladder Conditions

___ Heart Disease

___ Asthma

___ Liver / Gall Bladder Conditions

___ Aneurysm

___ Chronic Respiratory Conditions

___ Cancer

___ Anemias / Blood Disorders

___ Chronic Sinus Conditions

___ Reproductive System Conditions

___ Blood Clots / Phlebitis

___ Allergies

___ Other Circulatory Conditions

Are you currently:

Taking any prescribed medications?

Yes

___________________________________________________

Taking any over the counter medicines,

Yes

___________________________________________________

supplements, herbs, etc.?

___________________________________________________

Using any prosthetics?

Yes

___________________________________________________

(including contacts & dentures)

Have you ever had any:

Hospitalizations/Surgeries

Yes

__________________________________________________

Accidents/Injuries

Yes

__________________________________________________

Broken/Dislocated Bones

Yes

__________________________________________________

Have you ever experienced professional

Yes

How recently? ______________________________________

massage or bodywork?

Massage Therapist Use Only:

__________________________________________________________________________________________________

Client Intake Form

Related Articles

Related forms

Related Categories