Massage New Client Intake

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.

Signature __________________________________________________. Date ________________________

Full Name*

First NameMiddle NameLast Name

Date*

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Birth Date

MonthDayYear

Phone Number*

This is my:*

home, cell, work

E-mail*

example@example.com

Emergency Contact*

Phone Number*

Occupation

Are you on any pain medication or blood thinners? *

1. List Areas of Discomfort or Pain*

2. Describe Onset of Discomfort or Pain*

3. Rate of Pain Today*

4. Frequency - please select the most accurate

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

6. Have you ever injured this area before?*

7. Have you ever been in an accident (automobile, work, falls, etc.) ?*

8. List all related treatments received for this injury.

9. Have you ever received therapeutic massage for a specific problem or injury?

10. Have you ever had acupressure-style massage?*

11. Are you pregnant, or think you might be? (Please note that some acupressure points are contra-indicated for pregnancy and some area may be skipped altogether for safety). Please first get an approval from your physician before receiving this massage. *

12. Is there anything that you do that creates, increases or decreases pain? (explain the activity and whether this increases or decreases pain) *

13. What are the physical duties required of your occupation?*

14. What activities/hobbies do you engage in on a regular basis?

15. Are you currently seeing any other healthcare professional?

Any other sensations such as numbness, cold, swelling, cramps, or pins & needles? Describe the sensation and location.

Massage Policies:

Client services and chart information are confidential. Written authorization is required from you to release any information.

• Please turn off your cell phone for optimal relaxation

• Your scheduled session is set aside for you. We do not double book appointments

• 24 hour cancellation notice is required to avoid being charged for your session

• You will be clothed at all times for your session.

• You will have a consultation with your practitioner to discuss your session

• I understand that my therapeutic massage therapist or I may end the session at any time for any reason

• Inappropriate behavior will not be tolerated and may be prosecuted to the full extent of the law

Client Agreement:

I understand that therapeutic massage practitioners 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.

It is my choice to receive therapeutic massage as a form of relaxation, general health and well-being.

I undersand that at any time I feel pain or discomfort during the session, I will immediately inform my therapeutic massage practitioner so they can adjust.

I have stated my pertinent medical conditions, and will update the massage therapist of any changes in my health status, including pregnancy.

I understand that my failure to do so may post a threat to my health and/physical well being and I hold harmless my therapeutic massage practitioner from any liability whatsoever arising from failure on my part.

By my electronic signature below, I agree to the massage policy and client agreement above.

Today's date*

Signature*

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

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Amma Massage