Soma Sense Client Intake Form (Page 2 of 2) in pdf

Soma Sense Client Intake Form Page 2

Do you have any particular goals for this massage session? Yes No

If yes, please explain

What would you like to manifest in your life that you do not currently have or would like

more of?

Medical History

11. Are you currently under medical supervision?

Yes No

If yes, please explain

12. Are you interested in seeing a chiropractor? Yes No

13. Are you interested in learning self-massage/foam rolling techniques?

Yes

Are you currently taking any medication? Yes

If Yes, please list

14.

15. Is there anything else about your health history that you think would be useful for

your massage practitioner to know to plan a safe and effective massage session for

you?

I,______________________________________________

(print name) understand that the massage I receive

is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or

discomfort during this session, I will immediately inform the therapist so that the pressure and/or strokes

may be adjusted to my level of comfort. I affirm that I have stated all my known medical conditions,

and answered all questions honestly. I agree to keep the therapist updated as to any changes in my

medical profile and understand that there shall be no liability on the therapist’s part should I fail to do

so.

Signature of client ___________________________________ Date ________________________

Signature of Practitioner _____________________________ Date ________________________

Soma Sense Client Intake Form Page 2