Dreamcatcher Massage Client Intake

Client Intake Form

Full Name *

First Name Last Name

Date *

Month Day Year

Address *

Street Address

Street Address Line 2

City State

Zip Code

Birth Date *

Month Day Year

Phone Number *

E-mail *

Occupation *

Have you ever had a massage before? *

Are you now under medical, chiropractic or therapeutic care? If yes, please explain *

Please List any Medications and Allergies *

You can just list what conditions the medications are FOR, if you don't remember the names of them

Are you pregnant? *

Massage is not performed in the first trimester

Health History

1. List Areas of Current Discomfort or Pain *

2. Describe any accidents, injuries, or operations in the last 5 years *

3. Rate of Pain Today *

4. Frequency - please select the most accurate *

Constant Off/On At Rest With Activity

5. At what time of day is the pain at its worse? *

Morning Afternoon Evening During Sleep

What areas do you want focus on and what areas do you want avoided, if any? *

What type of pressure do you prefer: Light, Medium/Firm or Deep? *

Is your goal today pain relief, relaxation, or both? *

Please check any that apply to you or have applied to you in the past:

Chronic Pain Strains or Sprains Pulled Muscles Whiplash Spinal or Disc Problems

How did you hear about us? *

Client Agreement

By signing below I understand and agree to the following:

Massage is provided for the purpose of relaxation/relief of muscular tension. If I experience any pain/discomfort during the session, I will immediately inform Leia so that the pressure may be adjusted to my comfort. I understand massage is not a substitute for medical examination, diagnosis, or treatment & that I should see a physician, chiropractor or other health care specialist for any mental/physical illness. I participate in the activity at my sole risk and responsibility; I release, indemnify & hold harmless Leia Crowe and Dreamcatcher Massage from/against all & any actions or claims which may be made by me or on behalf of myself. I understand that massage is not sexual in any way. I have stated all known medical conditions and answered all questions honestly and to the best of my knowledge.

Covid Precautions: I affirm that I have not had any symptoms (fever, dry cough, difficulty breathing) in the last 14 days, nor have I knowingly been in contact with anyone who has symptoms. I have not traveled outside the US in the last 30 days, nor have I been in contact with anyone who has. I understand that Leia Crowe and Dreamcatcher Massage cannot be held liable for any exposure to the virus or any other contagion. By signing below I understand and agree that I am getting services at my own risk and release Leia Crowe and Dreamcatcher Massage from any and all liability for the unintentional exposure or harm due to Covid19. We have improved and expanded our sanitation protocols to more thoroughly fight the spread of Covid19 and other communicable conditions.

Signature *

Sign by using a touch tablet/screen or left click and hold as you sign with your mouse. Clear