Massage Therapy Intake Form
ADVERTISEMENT
1
2Massage Therapy Intake Form
Name:______________________________________________
Date of Birth:______________________________________
Home Phone: (
)______________________Work Phone: (
)______________________Cell Phone: (
)_________________
E-mail address:_______________________________________________________________________________________________
Address:_________________________________________________________City:__________________St:_______Zip:_________
Referred by:___________________________________ Have you ever had a professional massage before?____________________
If so, how often?__________________________________ Do you exercise?_________ Frequency:__________________________
Please describe what type of excersice____________________________________________________________________________
Other daily activities:________________________________________ Occupation:_______________________________________
Primary Care Physician:_________________________________________ Chiropractor:__________________________________
How do you relieve stress or pain?_______________________________________________________________________________
What are the reasons for your visit today?
What are your other health concerns?
Describe any surgeries you have had:
Describe any accidents you have had:
List all conditions currently monitored by a Health Care Provider:
List any medications that you took today:
Please note all current and previous conditions:
Headache
Y
N
Stiff/painful joints
Y
N
Sleep Problems
Y
N
Neck, shoulder, or arm pain or
Y
N
numbness
Fatigue
Y
N
Low back, hip or leg pain or numbness
Y
N
Flu or cold symptoms in the last 48 hours
Y
N
Sciatica
Y
N
Sinus
Y
N
Depression
Y
N
Allergies to scents or lotions
Y
N
Blood clots
Y
N
Allergies, in gereral
Y
N
Stroke
Y
N
Arthritis
Y
N
Heart disease
Y
N
Osteoporosis
Y
N
High/low blood pressure
Y
N
Scoliosis
Y
N
Poor circulation
Y
N
Broken bones
Y
N
Asthma
Y
N
Disc problems
Y
N
Thyroid dysfunction
Y
N
Spasms/cramps
Y
N
Diabetes
Y
N
TMJ (jaw pain)
Y
N
Currently pregnant
Y
N
Tendonitis/bursitis
Y
N
Malignant cancer or tumors
Y
N
Spinal Problems
Y
N
Benign cancer or tumors
Y
N
Varicose Veins
Y
N
Describe, as needed, any conditions indicated above, or other conditions that you feel may be important
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business