Relax Massage Therapy Client Health Intake Form
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1
2Relaxing Note
Massage Therapy Client Health Intake Form
Patient Information
Name:__________________________________________________________________________
Address: ______________________________ City: ____________ State: _____ Zip: __________
Home Phone: ________________________ Work/Cell Phone: _____________________________
E-mail: _____________________________________ Occupation: __________________________
Date of Birth: ________________________
Emergency Contact Person: _____________________________ Phone: ______________________
Are you currently under a physicians care for an acute or chronic illness? Yes ___ No ____
If yes, please explain: _________________________________________________________
If yes, who is your health care provider: ___________________________________________
Are you currently taking any prescribed medication or dietary supplements? Yes ____ No _____
If yes, please explain: _________________________________________________________
Have you received a professional massage before? Yes _____ No _____, If so, when? __________
How did you hear about Relaxing Note? ________________________________________________
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 an (X) by all current conditions and (P) for all past conditions.
__ Abdominal / Digestive
__ Diabetes
__ Numbness / tingles
__ Accident
__ Fatigue
__ Pregnancy
__ Allergies
__ Fibromyalgia
__ Rash / fungus
__ Anxiety
__ Headaches / Migraines
__ Sinus problems
__ Arthritis/tendonitis
__ Hearing problems
__ Sleep difficulties
__ Asthma or lung cond.
__ Hernia
__ Spinal disorders
__ Athletes foot
__ High blood pressure
__ Sprain / Strain
__ Blood clots
__ Jaw pain / TMJ pain
__ Tension / Stress
__ Chronic pain
__ Low blood pressure
__ Vision problems
__ Circulatory / Heart cond.
__ Low back pain
__ Varicose veins
__ Constipation / Diarrhea
__ Mid back Pain
__ Whiplash
__ Depression
__ Muscle / bone injuries
__ Other
__ Decreased range of motion
__ Neck Pain
Elaborate on noted areas above: ______________________________________________________
________________________________________________________________________________
Please list any recent injuries or surgeries within the past 5 years: ____________________________
________________________________________________________________________________
Please list your stress-reduction activities, hobbies, exercise and/or sport participation: ___________
________________________________________________________________________________
________________________________________________________________________________
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