Client Intake Form printable pdf download

Client Intake Form

Personal Information

Name__________________________________________________

Today’s Date________________________

Address______________________________________________________________________________________________

City_____________________________________________

State____________________

Zip___________________

Phone Day _______________________ Phone Evening____________________ Birth date_____________________

Occupation______________________________ How did you hear about Q Bodyworks?_____________________

Emergency Contact ______________________________________ Phone Number ____________________________

_____________________________________________________________________________________________

Heath Information

What is your primary reason for seeking assistance? Please describe symptoms and when they began.

If you experience pain please rate your level of pain on a daily basis on a scale from 1 to 10:

(little pain) 1

5 6

10 (extreme pain)

Do you feel this affects your quality of life and/or daily activities?

Do you have secondary concerns that you would like addressed?

Please list over-the-counter and prescription medications.

Any other information you would like to provide your Massage Therapist?

Client Intake Form