Soma Sense Client Intake Form printable pdf download

Soma Sense Client Intake Form

Client Intake Form

Personal Information:

Name _____________________________ Phone (____) _______________________ DOB_______________________

Address___________________________________ City__________________ State______ Zip____________________

Email _______________________________________ Referred by___________________________________________

Occupation________________________________________________________________________________________

Emergency Contact______________________________Phone____________________________________________

The following information will be used to help plan safe and effective massage sessions. Please answer

the questions to the best of your knowledge.

Have you had a professional massage before? Yes No

How often would you like to receive massage?

Once per week( ) Once per month( ) Every other month( ) Several times a year( )

Do you have any difficulty lying on your front, back, or side? Yes

If yes, please explain

Do you have any allergies to oils, lotions, or ointments?

Yes No

Do you experience stress in your work, family, or other aspect of your life? Yes

If yes, how do you think it has affected your health?

(Please check all that apply)

muscle tension( )

anxiety( )

depression( )

insomnia( )

irritability( )

other( )

Is there a particular area of the body where you are experiencing tension, stiffness,

pain or other discomfort?

Yes

Soma Sense Client Intake Form