New Client Intake Form (Page 2 of 2) in pdf

What goals do you have in mind for this session?

MEDICAL HISTORY

In order to plan a session that is safe and effective, we need some general information about your medical history.

Are you currently taking any medication? ☐ Yes ☐ No

If yes, please list:

Please check any condition listed below that applies to you:

☐ contagious skin condition

☐ headaches / migraines

☐ osteoarthritis / tendonitis

☐ open sores or wounds

☐ allergies / sensitivity

☐ osteoporosis

☐ easy bruising

☐ heart condition

☐ epilepsy

☐ recent accident or injury

☐ high or low blood pressure

☐ cancer

☐ recent fracture

☐ circulatory disorder

☐ diabetes

☐ recent surgery

☐ varicose veins

☐ decreased sensation

☐ atherosclerosis

☐ back / neck problems

☐ artificial joint

☐ sprains / strains

☐ phlebitis

☐ fibromyalgia

☐ current fever

☐ deep vein thrombosis / blood clots

☐ TMJ

☐ swollen glands

☐ joint disorder / rheumatoid arthritis

☐ carpal tunnel syndrome

___________ months

☐ pregnancy; if yes, how many months?

☐ tennis elbow

Please explain any condition that you have marked above. Include any information that would be useful to know in planning a safe and

effective massage for you:

Draping will be used during the session. Only the area being worked on will be uncovered. Clients under the age of 17 must be accompanied by

a parent of legal guardian during the entire session. Informed, written consent must be provided by parent or legal guardian for any client under

the age of 17.

I, ____________________________________________, understand that the therapy 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 may be adjusted to my level of comfort. I further understand that massage/Reiki/professional skincare should not be construed as a

substitute for medical examination, diagnosis, or treatment, and that I should see a physician, chiropractor or other qualified medical specialist

for any mental or physical ailment that I am aware of. I understand that massage/Reiki/therapists/estheticians are not qualified to perform spinal

or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given

should be construed as such. Because massage should not be performed under certain conditions, 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 therapists’ part should I fail to do so.

Signature of

Client/Guardian:

Date:

Signature of

Therapist

Date

True Essence Tranquility New Client Intake Form

Page 2 of 2

New Client Intake Form Page 2

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