Massage Therapy Client Health Intake Form printable pdf download

Massage Therapy Client Health Intake Form

ATHLETIC EDGE

MASSAGE THERAPY CLIENT HEALTH INTAKE FORM

PATIENT INFORMATION

NAME: ___________________________________________________________________

ADDRESS:_______________________________________ CITY: ___________________

STATE: _______ ZIP_____________ HOME PHONE:_____________________________

WORK PHONE: ________________________ CELL PHONE: ______________________

E-MAIL: __________________________________________________________________

OCCUPATION: _____________________________ DATE OF BIRTH: ______________

EMERGENCY CONTACT: _____________________________ PHONE: _____________

ARE YOU CURRENTLY UNDER A PHYSICIANS CARE FOR AN ACUTE OR CHRONIC

ILLNESS? Y _____ N ______

IF YES, PLEASE EXPLAIN __________________________________________________

IF YES, WHO IS YOUR HEALTH CARE PROVIDER: ____________________________

ARE YOU CURRENTLY TAKING ANY PRESCRIBED MEDICATION OR DIETARY

SUPPLEMENTS? Y _____ N ______

IF YES, PLEASE EXPLAIN __________________________________________________

HAVE YOU RECEIVED A MASSAGE BEFORE? Y _____ N ______

IF YES, WHEN: _________________________

HOW DID YOU HEAR ABOUT ATHLETIC EDGE: _____________________________

WHAT ARE YOUR GOALS FOR THIS SESSION: _______________________________

PLEASE LIST AREAS OF TENSION, STRESS AND/OR PAIN YOU WISH TO BE

ADDRESSED: _____________________________________________________________

_________________________________________________________________________________

HEALTH INFORMATION

PLEASE MARK AND (X) BY ALL CURRENT CONDITIONS AND (P) FOR ALL PAST

CONDITIONS

ELABORATE ON NOTED ABOVE AREAS: __________________________________________

________________________________________________________________________________

Massage Therapy Client Health Intake Form