Client Intake Form - Massage
ADVERTISEMENT
1Client Intake Form – Massage
Name: __________________________________________ DOB: ________________
Address: __________________________________ Occupation: __________________
City: ___________________________ State: ___________ Zip: _________________
Phone Number: __________________________ Other: _________________________
Emergency Contact: ________________________ Relationship: _________________
Phone Home/Work/Cell: ___________________________________________________
Have you ever received a massage before? Yes or No How often? _____________
Check any of the following that apply to your current health:
__pregnancy
__hear conditions
__circulatory conditions __blood clots
__infections
__cancer
__difficulty breathing
__arthritis
__diabetes
__athletes foot
__headaches
__cold/flu
__stress
__neck pain
__back pain
__shoulder pain
__knee pain
__varicose veins
__allergies
__sinus pain
__other conditions: _______________________________________________________
Please list any medications you are currently taking: _____________________________
________________________________________________________________________
If today’s visit is due to pain in a certain area please list where the pain is and rate it on a
scale of 110, 10 being the worst: ____________________________________________
Please list the following to the best of your knowledge:
Recent surgeries: ___________________________________________ Date: _______
___________________________________________ Date: _______
Accidents: _________________________________________________ Date: _______
Major illness: ______________________________________________ Date: _______
CONSENT FOR CARE
It is my choice to receive massage therapy. I am aware of the benefits and risks of
massage and give my consent for massage. I understand that there is no implied or stated
guarantee of success of effectiveness of individual techniques or series of appointments.
I acknowledge that massage therapy is not a substitute for medical care, medical
examination, or diagnosis. I have stated all medical conditions that I am aware of and
will inform my therapist of any changes in my health status.
Signature: _______________________________________________ Date: _________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business