New Client Intake Form printable pdf download

New Client Intake Form

NEW CLIENT INTAKE FORM

Name:

Birthdate:

Home #:

Cell #:

Work #:

Address:

City:

State:

Zip:

Email:

Emergency

Contact #:

Name/Relation to you:

Occupation:

How do you prefer to be contacted? ☐ Cell ☐ Home ☐ Work ☐ Email ☐ Facebook

Who referred you / how did you hear about us? We would like to thank them!

May we contact your place of business for promotional opportunities / chair massages? ☐ Yes If yes, who is your employer?

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 professional massage / Reiki / shiatsu / skincare before? ☐ Yes ☐ No

If yes, how often do you receive?

Do you have any difficulty lying on your front, back or side? ☐ Yes ☐ No

If yes, please explain:

Do you have any allergies to oils, lotions or ointments? ☐ Yes ☐ No

If yes, please explain:

Do you have sensitive skin? ☐ Yes ☐ No

Are you wearing ☐ contact lenses ☐ dentures ☐ a hearing aid? ☐ None

Do you sit for long hours driving, or sitting at a workstation or computer? ☐ Yes ☐ No If yes, please describe:

Do you perform repetitive movement in your work, sports or hobby? ☐ Yes ☐ No

If yes, please describe:

Do you experience stress in your work, family or

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

other aspect of your life? ☐ Yes ☐ No

☐ Muscle tension ☐ Anxiety ☐ Insomnia ☐ Irritability ☐ Other

Is there a particular area of the body where you are experiencing tension, stiffness, pain, skin irritation or other discomfort? ☐ Yes ☐ No

If yes, please identify:

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New Client Intake Form