New Client Intake Form (Page 2 of 2) in pdf

____Chronic pain

____Multiple Sclerosis

____Paralysis

____Parkinson’s disease

____Epilepsy

____Fibromyalgia

Skin

____Rashes

____Fungus/athletes foot

____Herpes/cold sores

Digestive

____Diarrhea

____Crohn’s/Colitis

____Bladder/Kidney Ailment

____Ulcers

____Constipation/IBS

____Diabetes

Psychological ____Sleep disorder

____Depression

____Anxiety/stress syndrome

Other

____Wear contacts

____Hearing impaired

____Drug/alcohol/tobacco use

____Cancer/Tumors

Please list any conditions not addressed previously or explain checked items above:

__________________________________________________________________________________________________

Please take a moment to read the following information:



I understand that massage therapy is provided for stress reduction, relaxation, relief from muscular tension, and

improvement of circulation and energy flow.



If I experience pain or discomfort during the session, I will immediately inform my therapist so that

pressure/strokes can be adjusted to my level of comfort. I will not hold my therapist responsible for any pain or

discomfort I experience during or after the session.



I understand that the services offered today are not a substitute for medical care. I understand that my therapist

is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat physical or mental illness.



I affirm that I have notified my therapist of all known medical conditions and injuries.



I understand that massage is entirely therapeutic and non-sexual in nature.



Prior to your massage, please remove contact lenses and all jewelry. Pull long hair back with a clip or band.

Feel free to ask your therapist any questions before, during, or after the session. Your therapist is highly trained

professional and will be happy to make you feel informed and comfortable.

_________________________________________

_______________

Client signature

Date

New Client Intake Form Page 2

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