Massage Therapy Client Intake

Massage 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 Date

Day Month Year
Address *

Street Address

Street Address Line 2

City

Postcode Country
Phone Number *

Area code Phone Number
E-mail *
example@example.com
Emergency Contact *
Phone Number *

Area Code Phone Number
History History
Please tick if you had, or are suffering from any of the following conditions:
Medication *

Diabetes Epilepsy Cancer Depression Asthma M.S. High/ Low Blood pressure Back/Neck problems Eczema/psoriasis Allergies Heart PMT Menopause Irregular periods Pregnant or trying Foot disorders None above
Neck

Stiffness Pain at neck shoulder junction Pain when turning head Pain with side to side movements Neck feels out of place Muscle spasm in neck Gliding/Grating sound with neck movement Diagnosed bone spurs Diagnosed disc herniation
Shoulders

Pain in shoulder Front Back Side Pain deep in shoulder joint Diagnosed bursitis Diagnosed Arthritis Can't raise arm above shoulder level Can't raise arm over head
Arms & Hands

Pain in upper arm Pain in forearm Pain in wrist Pain in fingers Sensation of pins & needles in arm Sensation of pins & needles in fingers Fingers go to sleep Hands cold Swollen joints in fingers Sore joints in fingers Diagnosed arthritis Loss of grip strength
Mid-Back

Mid-back pain Pain between shoulder blades Pain up/down back Pain across mid back Pain with breathing
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 stooping 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 Pinched nerve in low back Low back feels out of place Pain up/down low back Pain across low back Diagnosed disc herniation
Hip

Pain in buttocks Pain in buttocks when standing Pain buttocks in buttocks when sitting Pain on side of hip Pain deep in hip joint Pain on sit bone Diagnosed bursitis Diagnosed arthritis
Legs and Feet

Pain down RIGHT leg Pain down LEFT leg Pain down BOTH legs Leg cramps Pin & Needles in RIGHT leg Pin & Needles in LEFT leg Numbness in RIGHT leg Numbness in LEFT leg Numbness in RIGHT foot Numbness in LEFT foot Numbness in toes Feet feel cold Cramps in RIGHT foot Cramps in LEFT foot Swollen RIGHT ankle Swollen LEFT Ankle Swollen RIGHT foot Swollen LEFT foot Pain in RIGHT Foot Pain in LEFT Foot Pain in RIGHT knee Pain in LEFT knee Diagnosed Arthritis
I authorize this massage spa clinic/center to perform the treatment or necessary procedure for my child.

I authorize the use of lotion, oil, and ointments to my body.

I acknowledge that I have consulted a physician before undergoing this massage treatment. I understand that I should consult my doctor before the procedure.

I understand that this is an alternative treatment and if there are any medical concerns, I need to talk to my physician.

I acknowledge that this massage therapy has no sexual intent and touching the therapist is strictly prohibited.

I release this massage spa clinic/center for any responsibility in case of an accident, illness, or injury.

I acknowledge that all information I provided int his form is true and accurate.
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