Client Intake Form
Massage Therapy | Energy Healing | Reflexology | Health Coaching
E.g., They/them, she/her, he/him
Cell Phone Number
I will send you a text reminder the day before your appointments.
Street Address Line 2
Emergency Contact Phone
Please enter a valid phone number.
In order for me to provide you with the best and safest care, it is imperative that you provide accurate health information. Please answer all questions completely. All information will be kept strictly confidential. The health information gathered cannot be shared with any other healthcare provider unless you provide us with your written consent.
Date of Birth
Do you have any allergies? Please list all:
Please advise if you have any impairments. Select all that apply:
Require mobility aids (wheelchair, walker, cane, crutches)
If "Other" please explain:
Are you currently seeing a Physician (MD), Chiropractor, or Physical Therapist for an ongoing issue? If yes, please explain.
Are you pregnant? If yes, please include due date.
Do you currently have an injury? (E.g., sprain, fracture, broken bone, whiplash). If so, please explain.
Are you currently receiving medical treatment? (E.g., chemotherapy, antibiotics, mental health counselling, IVF, etc.)
Are you currently taking any medications? Please include all prescription drugs and over-the-counter drugs (such as Tylenol or Zyrtec).
Please list any surgeries in the last 5 years:
Please check off any conditions that apply to you, past and present. Include your comments under each condition.
Musculoskeletal System History
Broken or fractured bones
Sprains or strains
Jaw pain or TMJ syndrome
Muscle spasms or cramps
Musculoskeletal System Comments:
Integumentary System History
Contact Dermatitis (skin allergies)
Integumentary System Comments:
Cardiovascular & Respiratory System History
Hypertension (high blood pressure)
Hypotension (low blood pressure)
Cardiac Arrythmia (irregular heart rate)
Pacemaker (if yes, please include the date in the comments)
Shortness of breath
Cardiovascular & Respiratory System Comments:
Nervous System History
Chronic Fatigue Syndrome
Herpes or Shingles
Numbness or tingling
Nervous System Comments:
Digestive System History
Irritable Bowel Syndrome
Intestinal gas or bloating
Digestive System Comments:
Please include any other health history information that you would like us to be aware of.
Massage Therapy Waiver & Declaration
By signing, I agree to the following. I understand that massage therapy is provided for stress reduction, relaxation, relief from muscular tension, and improvement of circulation and energy flow. If I experience pain or discomfort during the session, I will immediately inform my therapist so that pressure/strokes can be adjusted to my level of comfort. I will not hold my therapist responsible for any pain or discomfort I experience during or after the session. I understand that the services offered today are not a substitute for medical care. I understand that my therapist is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat physical or mental illness. I affirm that all of the information that I have provided in my health history form is accurate. I acknowledge that to ensure appropriate treatment it is of upmost importance to inform my massage therapist of any old, current, or new injuries as well as inform them of any changes in my health status, or and concerns I may have, and I understand that there shall be no liability on the therapist’s part should I forget to do so. I understand that massage is entirely therapeutic and non-sexual in nature. By signing this release, I hereby waive and release my therapist from any and all liability, past, present, and future relating to massage therapy and bodywork.
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