Massage Client Intake Form printable pdf download

Massage Client Intake Form

Elizabeth Bosse, Licensed Massage Therapist and Energy Worker

Client Intake Form

Name:________________________________________________________ Email: _____________________________

Address:_______________________________ City:________________________ State:_______ Zip:____________

Phone:(best way to reach you) ( ) C:_________________ ( ) H:________________ ( ) W: ________________

Occupation:_____________________________________________________________________________________

Referred by:_______________________________________________________ Date of Birth:_____/_____/_____

Emergency Contact:_____________________________________________ Phone:___________________________

Have you experienced any previous bodywork or energy work? Y or N

If yes, when and what kind?________________________________________________________________________

Are you currently under a physician’s care for any condition? Y or N

If yes, please explain:______________________________________________________________________________

Physicians’ Name: ___________________________ Phone:____________________ Fax:______________________

What issues bring you in today? These symptoms can be physical, mental, emotional, or

spiritual.

________________________________________________________________________________________

How long have you been experiencing this? ________________________________________________

Have you been given a medical diagnosis? Y or N? Please Explain:______________________________

Are there behaviors or thoughts that aggravate the situation? _________________________________

________________________________________________________________________________________

Massage Client Intake Form