Massage Therapy Client Intake

Massage and Yoga Therapy Client Intake Form

All information is held strictest confidence. At no given point is information disclosed or shared without client’s written consent. You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose.
Full Name *

First Name Last Name
Birth Month
Address *

Street Address

Street Address Line 2

City State

Zip Code
E-mail *
Phone Number *
Emergency Contact *
Emergency Phone Number *
Where is your pain or Discomfort? *
What precipitated your Pain or Discomfort *
Please rate your pain today *
Frequency - please select the most accurate *

Constant Off/On At Rest With Activity
At what time of day is the pain at its worst? *

Morning Afternoon Evening While Sleeping - pain wakes you
Is there anything that you do that creates, increases or decreases pain?
In what position do you most often wake up? *

Back Side Stomach
Have you ever been in an accident (automobile, work, falls, etc.) ? *
If yes, list all diagnoses and/or treatments you received after the accident
What do you do for exercise? How often? *
What do you do to relieve stress? How often? *
Please list all current medications including herbs
Please check any symptoms that apply to you and indicate right or left when applicable:
Head

Temples Forehead Top of head In the eyes Entire head Base of skull Dizziness Fainting Light-headedness Pain in ears Ringing in ears
Neck

Stiffness Pain at neck shoulder Pain when turning head Pain with side to side movement Muscle spasm in neck Grinding/Clicking Sound Worse in the morning Worse in the evening Have you had a medical diagnosis for this issue? Have you had surgery in this area?
Shoulders

Pain in shoulder Front Back Side Pain in shoulder joint Pain raising arm Can't raise arm Have you had a medical diagnosis? Have you had surgery in this area?
Arms & Hands

Pain in upper arm L or R Pain in forearm L or R Pain in wrist L or R Pain in fingers Pins & needles in arm L or R Pins & needles in fingers L or R Fingers go to sleep Cold Hands Swollen joints in fingers Sore joints in fingers Loss of grip strength Have you had a medical diagnosis? Have you had surgery in this area?
Mid-Back

Mid-back pain Pain between shoulder blades Pain up/down back Pain across mid back Pain with breathing Have you had a medical diagnosis? Have you had surgery in this area?
Low Back

Low back pain Low back pain is worse when working Low back pain is worse when lifting Low back pain is worse when standing Low back pain is worse when sitting Low back pain is worse when bending Low back pain is worse when coughing Worse in the morning Worse in the evening Radiates down Radiates up Pain across low back Have you had a medical diagnosis? Have you had surgery in this area?
Hip

Pain in buttocks Worse when standing Worse when sitting Worse lying down Pain on side of hip Pain deep in hip joint Pain on sitting bone Worse in the morning Worse in the evening Diagnosed bursitis Diagnosed arthritis Have you had another medical diagnosis? Have you had surgery in this area?
Legs and Feet

Pain down one leg L or R Pain down BOTH legs Leg cramps L or R Pin & Needles L or R Numbness in leg L or R Numbness in BOTH legs Knee Pain L or R Knee Swells L or R Numbness in foot/toes L or R Feet feel cold FootCramps L or R Foot and/or Ankle swollen L or R Foot Pain L or R Have you had a medical diagnosis? Have you had surgery in this area?
Specfic Medical Conditions

If you have ever had any of the following please check P for “past”, C for “current” or N for “no”

Skin Conditions ( rashes, infections, itching, etc. )

Allergies

Cardiovascular Conditions ( heart attack, angina, high blood pressure, etc. )

Liver or Kidney Conditions

Respiratory Conditions

Cancer or Tumors (malignant or benign)

Diabetes

Arthritis

Pregnancy

Injuries (disc problems, tendinitis, knee problems, fractures, etc. )

Headaches ( chronic, severe, etc. )

Other conditions not mentioned above

Massage Policies and Agreements

Client services and information are confidential. Written authorization is required from you to release any information to other healthcare providers, insurance, or other individuals.

• Please turn off your cell phone prior to entering the treatment room.
• Please reschedule your session if you are more than 15 minutes late.
• 24-hour cancellation notice is required to avoid being charged for your session

I understand that massage therapists do not diagnose illness, disease, any physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals, or perform joint mobilization.

I acknowledge that massage therapy is not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for that service.

All information provided here is current and complete. I understand that my failure to disclose any medical condition may pose a threat to my health and well-being and I hold harmless Robin Lamperti from any liability whatsoever arising from failure on my part.

I agree that all the information provided is accurate and complete, and I agree to the massage policies and client agreement as stated above.
Signature *

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