Client Intake Form

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client intake form
client signature
date of initial visit
personal information
current health
Do you exercise regularly and/or participate in any sports?
r
r
Y
N
name
If yes, what kind of exercise/sports?
address
Do you perform any repetitive movement in your
r
r
Y
N
work, sports or hobby?
city
state
zip
If yes, describe
home phone
cell phone
Do you sit for long hours at a workstation, computer
r
r
Y
N
work phone
or driving?
If yes, describe
email
occupation
Do you experience stress in your work, family, or other
r
r
Y
N
aspect of your life?
marital status
If yes, describe
referred by
Are you experiencing tension, stiffness, discomfort or pain?
r
r
Y
N
emergency contact name
emergency contact phone
If yes, describe
physician’s name
physician’s phone
Have you recently had an injury, surgery, or areas of
r
r
Y
N
inflammation?
massage experience
If yes, describe
Have you had a professional massage before?
r
r
Yes
No
Do you have sensitive skin?
r
r
If yes, what types of massage have you had (swedish, shiatsu, deep tissue, etc.)?
Y
N
Do you have any allergies to oils, lotions or ointments?
r
r
Y
N
If yes, please explain
How long have you been receiving massage therapy?
List any medications you are currently taking
Frequency of massages?
What are your goals for treatment?
List any known allergies
health history
Musculoskeletal
Respiratory
Skin
Other
Bone or joint disease
Breathing Difficulty/Asthma
Allergies, specify:
Cancer/Tumors
Tendonitis/Bursitis
Emphysema
Diabetes
Arthritis/Gout
Allergies, specify:
Rashes
Drug/Alcohol/Tobacco Use
Jaw Pain (TMJ)
Cosmetic Surgery
Contact Lenses
Lupus
Sinus Problems
Athlete’s Foot
Dentures
Spinal Problems
Herpes/Cold Sores
Hearing Aids
Nervous System
Migraines/Headaches
Digestive
Shingles
Any other medical condition(s) not
Osteoporosis
Numbness/Tingling
Irritable Bowel Syndrome
listed:
Circulatory
Pinched Nerve
Bladder/Kidney Ailment
Heart Condition
Chronic Pain
Colitis
Phlebitis/Varicose Veins
Paralysis
Crohn’s Disease
Please explain any of the conditions
Blood Clots
Multiple Sclerosis
Ulcers
that you have marked above :
High/Low Blood Pressure
Parkinson’s Disease
Psychological
Lymphedema
Reproductive
Anxiety/Stress Syndrome
Thrombosis/Embolism
Pregnant, stage
Depression
_______________
Ovarian/Menstrual Problems
Prostate
This form was created as a resource by the american massage therapy association®
and they are not held liable for any services provided.

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