Massage Therapy Intake Form

Client Intake Form

Please complete a new intake form every 12 months
Full Name (no initials)*

First NameLast Name
Gender*

MaleFemaleOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

DayMonthYear
Date
Phone Number*
Occupation*
This can help identify common problem areas
Health Fund (if claiming a rebate)*

MedibankBupaHCFNIBNoneOther
Emergency Contact Details*
Name, phone number and relationship to you
Details of previous professional massage
e.g. type of massage, conditions treated, results of treatment
Referred by
e.g. friend's name, Google search, Facebook page
Reason for seeking massage*
e.g. neck/shoulder pain, low back pain, tight hamstrings, sports injury
Regular exercise / physical activity*
e.g. work/home activity, walking/cycling to work, gym, sports
Do you currently or frequently have any of the following?*

Low back painNeck painHeadachesNone
Are you currently experiencing any of the following?*

Pain/tendernessNumbness/tinglingStiffnessSwellingAllergiesNone
Please provide details if you selected any above
e.g. severity, location, type, any allergens
Are you now under medical / therapeutic treatment?*

YesNo
If so, for what condition(s)?
Describe conditions being treated
Illnesses, injuries or conditions you have now or in the past 3 years*

Bone or joint; sprains / strains; soft tissueOsteoporosisArthritisHeadaches / sleep disordersNumbness / tingling / weaknessHeart conditionsVaricose veins / blood clotsHigh / low blood pressureBreathing difficultiesSinus problems / hay fever / asthmaAllergies / skin disordersConstipation / bloatingPregnancyCancerDiabetesEpilepsyLymphatic systemNoneOther
Please provide details if you selected any above
Describe illnesses, injuries or conditions and when you had them
Medications taken in the past week*

PainAnti-inflammatoriesBlood thinnersRespiratoryPsychiatricNoneOther
Please provide details if you selected any above
Name of medication and when taken
I consent to massage therapy and associated rehabilitation support (movement assessment, exercise guidance and pain education) provided by Brendan Lo (AMT member). I have provided my medical history and understand the therapist cannot anticipate conditions I have not disclosed. I understand results are not guaranteed. Possible temporary effects include muscle soreness, mild bruising, increased awareness of pain, light-headedness, and (if guided movements/exercises are included) muscle fatigue or soreness. I understand the therapist does not diagnose illness, prescribe medication, or perform spinal manipulation. I may ask questions at any time and will inform the therapist of any discomfort so treatment can be adjusted or stopped at my request.
Signature*

Clear
Date*

DayMonthYear
Date
Should be Empty:

Client Intake Form