Client Intake Form (Massage)

Client Intake and History Form - Therapeutic Massage l Bodywork

Personal Information:

Name

First NameLast Name

Date of Birth

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

Email

example@example.com

Have you ever had a professional massage before?

If yes, how often do you receive massage therapy?

Do you have difficulty lying on your front, back, or side?

If yes, please explain:

Please list allergies or sensitivities:

Do you sit for long hours at a workstation, computer, or driving?

Do you perform repetitive movements in your work, sports, or hobbies?

Do you experience stress in your work, family, or other aspect of your life?

If yes, how do you think it has affected your health?

Do you have particular goals in mind for this massage session?

Are you currently under medical supervision?

If yes, please explain:

Are you taking any medication?

If yes, please list:

Do you see a Chiropractor?

If yes, how often?

Please check all that apply:

Client Information - Informed Consent - Waiver

1. I understand that massage therapists are not medical doctors and do not diagnose illness, disease, or any physical or mental disorder. I acknowledge that massage and related bodywork therapies are not substitutes for medical treatment and that KM5 recommends that clients see a primary healthcare provider for that service. I understand that it is my responsibility to share any concerns or questions about my session with my massage therapist. I do not have injuries or conditions that would prevent me from receiving a massage, nor have I been told by a healthcare provider that I should not receive a massage or complementary therapies.

2. I understand that massage therapy and bodywork are therapeutic services and are non-sexual. I acknowledge that my massage therapist reserves the right to end a therapy session in case of sexual innuendo or advances from the client. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the massage and that I will be liable for full payment of the scheduled session.

3. Any information exchanged during a massage or bodywork session is confidential and is only used to provide me with the best services available. I understand that a massage therapist will ask me questions about my health and physical condition and that I am obligated to my health history in complete detail.

4. I understand that my feedback is essential for treatment and that if I experience any discomfort or pain during my session, I must inform the therapist so that the therapist can adjust the pressure or technique.

5. The therapist reserves the right to decline, discontinue, or restrict services based on any provided information that may indicate a health risk to me to the massage therapist.

6. I acknowledge that I am responsible for being on time for my appointments and that the therapist is not under any obligation to extend my therapy session. I also agree that if I am late, I am responsible for the time I have booked. I understand that my appointment time is reserved for me only. If I miss an appointment or fail to give twenty-four hours' notice when I need to change or cancel, I agree to pay the company in full for the booked appointment time.

7. I understand that massage therapy and bodywork are for stress reduction, relief from muscular tension, myofascial restriction, general well-being, and improving energy flow.

8. I understand that the practitioner does not prescribe medical treatment or pharmaceuticals, nor do they perform any spinal adjustments.

9. I understand that services offered today and in the future are not a substitute for medical care and that any information provided to me by the therapist is purely for educational purposes and isn't diagnostically prescriptive.

10. I have stated all my medical conditions on the Client Intake Form. I have consulted a medical doctor or licensed medical healthcare practitioner regarding any checked or prescribed conditions.

11. I understand that it is my responsibility to report any changes in my physical health to my therapist. I further understand that KM5 shall not be liable for any purpose or reason should I fail to report the needed information as per this paragraph.

12. I have reviewed this form in its entirety and discussed all of my treatment concerns with my therapist.

Date

Signature