Client Intake Form - 9th St Wellness Center
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11028 Ninth Street, Green Bay, WI 54304
Client Intake
Phone: (920) 490-9699
Form
(Please Print)
Name ______________________________________________________ DOB _________________________
Phone ________________________ Email ______________________________________________________
Address__________________________________________________________________________________
City ______________________________________ State _____________ Zip Code ____________________
Emergency Contact_____________________________________ Phone _____________________________
Referred by___________________________Reason for initial visit ___________________________________
Have you had a massage before? Yes
No
Injuries or Surgeries in the past? Yes
No
Please describe ____________________________________________________________________________
Allergies __________________________________________________________________________________
Medications _______________________________________________________________________________
Pregnant Yes
No How far along? ___________________________
______ Arthritis
______ Autoimmune
______Bruise easily
______ Cancer
______ Car Accident
______Carpal Tunnel
______Depression
______ Diabetes
______ Disc Problems
______Epilepsy
______Headaches/Migraines
______ Heart condition
______ High/Lo Blood Pressure ______Numbness/Tingling
______Old injuries
______ Plantar Fasciitis
______ Plantar Warts
______ Rotator cuff injury
______Sciatica
______ Scoliosis
______ Sinus Problems
______TMJ
______ Varicose Veins
______Skin conditions
Comments________________________________________________________________________________________
Areas you would
NOT
like worked on: _____ Back _____Neck _____ Shoulders _____Hips _____Buttocks_____Face
_____ Feet _____Arms _____Hands _____Scalp _____Abdomen _____Other
The above information is accurate to the best of my knowledge, and I freely give my permission to be massaged. I agree to inform
the therapist of any experience of pain or discomfort during the session. I understand this does not deter me from seeking medical
treatment for medical conditions. I understand that no inappropriate comments or conduct will be tolerated. Any indications of
such behavior will automatically end the session.
I agree to update the massage therapist in regard to changes in my health and understand that there shall be no liability on the
therapist’s part if I forget to do so. I agree to hold harmless the establishment, its employees, and the therapist from and against
any and all claims. I agree to handle suit at its sole expense and agree to bear all costs related even if claims are groundless, false
and fraudulent.
Signature_________________________________________________________________
Date ______________________
Therapist Signature_________________________________________________________
Date______________________
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