New Client Intake Form
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2New Client Intake Form
Massage Therapy at Craddock Wellness Center
Personal Information
________________________________________________
Name
________________________________________________
_______________________________________
Address
Home or work phone
________________________________________________
_______________________________________
City
State
Zip
E-mail address
________________________________________________
_______________________________________
Emergency Contact name
Emergency phone number
Massage Experience
Have you ever received massage?
Yes
No
If yes, what type?
_____________________________________________________________________
When was your last massage? ________________________________________________________________
Frequency of massages: _____________________________________________________________________
What are you goals for treatment? __________________________________________________________________
Health History
Please check all that apply to you, past and present. Add any additional comments to clarify a condition where necessary.
It is your responsibility to inform the therapist of any health/medical changes.
Pregnancy
Are you pregnant?
Yes
No
If so, a prenatal release form must be completed in addition to this intake form.
Musculoskeletal
____ Headaches/Migraines
____Tendonitis/bursitis
____Bone or joint disease
____Arthritis/RA/gout
____Muscle spasms/cramps
____Osteoporosis/Scoliosis
____Back pain
____Lupus
____Shoulder/neck/arm/hand
____Carpal Tunnel Syndrome
____Leg/foot
____Jaw pain
Circulatory
____Heart conditions
____Blood pressure: High/Low
____Varicose veins/phlebitis
____Swelling
____Blood clots/DVT/embolism
Nervous System
____Shingles
____Numbness/tingling
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