Massage Therapy Client Intake

Client Intake Form

All information submitted will remain strictly confidential. At no point is information shared without a client’s consent. You may choose not to answer any question you feel impinges on personal information you do not wish to disclose. However, the more you share, the more I may be able to help. Thank you for your time!

Date *

Month Day Year

Full Name *

First Name Middle Initial Last Name Suffix

Pronoun (i.e. She/Her, He/Him, They/Them, Etc.)

Birth Date *

Month Day Year

Address *

Street Address

Street Address Line 2

City State

Zip Code

Phone Number *

E-mail *

Emergency Contact *

Phone Number *

Occupation

Medications

Allergies *

How did you find out about my services? *

History of Pathology

1. Please list area of discomfort, pain or impairment, if any. Feel free to get as detailed as you would like. If multiple areas are involved, there is space near the bottom of this form where you can get more specific.

2. Describe onset of condition or symptoms, if applicable. (When did you first notice it?)

3. Frequency of symptoms, if applicable. Choose more than one if that applies.

Constant Off & On At Rest With Activity

4. At what point in your day are symptoms worse, if applicable? (For instance, when you wake up, while sleeping, throughout the day, while doing a certain activity, etc.)

5. Have you ever injured this area before? If so, please describe when and how it affected you, including treatments received.

6. Is there anything you do that creates or increases pain?

7. Is there anything you do that decreases and soothes pain?

8. Rate of pain today on scale of 0-10

9. Have you ever been in an accident (automobile, work, falls, etc.)? If so, please describe when and how it affected you.

10. Have you ever had surgery? If so, you may list what type and when you had it.

11. Do you manage any type of emotional distress or mental illness (such as depression, anxiety, PTSD, etc.)? If you're comfortable sharing, you may do so below. A common theory is that all of this gets stored in the body so I find it helpful to be aware of.

12. Are you a survivor of any physical or sexual violence / unwanted physical contact? I want everyone in my space to feel safe so I consider it valuable to know, but only if it feels right to share.

13. What are the physical duties required of your occupation, hobbies, or other activities?

14. Feel free to list exercise and stress reduction activities (including frequency).

15. In what position do you most often sleep? (Choose more than one if that applies.)

Back Side Stomach A combination

16. Please describe the quality of your sleep.

I sleep like a baby and get at least 7 hours every night. I sleep soundly and get at least 7 hours most nights. I sleep soundly but get less than 7 hours most nights. I deal with insomnia or other chronic sleep related issues that prevent me from getting quality sleep.

17. Are you currently seeing any other healthcare professional? If so, please indicate which type and frequency with which you receive their services.

18. Have you ever received therapeutic massage?

19. If so, what level of pressure do you generally prefer massage therapists use?

20. What are you hoping to get out of your massage session? *

21. Is there anything else you feel it's important I know?

If various symptoms or conditions are present in multiple areas, please indicate which areas of your body are affected and what your experience is like. Be sure to mention which side of the body is affected or if it's both, when applicable.

HEAD:

NECK:

SHOULDERS:

ARMS & HANDS:

BACK:

HIPS & BUTTOCKS:

LEGS & FEET:

Massage Policies

* All clients' information is kept confidential and will only be released with consent.

• Please be on time and notify your therapist if you're going to be late to ensure there will be enough time for your session.

• 24-hour cancellation notice is expected in order to avoid being charged half the regular rate of the service a client is scheduled to receive. Exceptions apply in emergency situations or when someone falls ill.

• A consultation will be provided prior to your session to discuss any of your questions and concerns, as well as identify personal preferences and treatment goals.

• For optimal enjoyment, it is recommended that you turn sounds and notifications off on your cell phone during your session.

• You will be modestly draped the entire time and are encouraged to disrobe after the therapist has left the room only to a level you are comfortable with.

• Either the massage therapist or client may end the session at any time for any reason but clients may still be charged for a full session depending on the circumstances.

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

Client Agreement:

I understand that licensed 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.

It is my choice to receive therapeutic massage as a form of therapy.

I understand that treatment given is designed to address the care and prevention of myofascial pain and dysfunction.

I also undersand that at any time I feel pain or discomfort during the session, I will immediately inform my massage therapist so they can make adjustments to their approach.

I have shared all pertinent medical information, and will update the massage therapist of any changes in my health status.

I understand that my failure to do so may pose a threat to my health and physical well being and I hold harmless this massage therapist from any liability whatsoever arising from failure on my part.

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

Signature *

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

At Vital Flow, we believe wellness practices should be accessible to everyone and that's why we've created the Wellness For All program which allows us to provide massage therapy services to folks who may not be able to afford it at the regular rates. If this applies to you or if you know someone who may benefit from this program, please mark one of the responses below. Qualifying for the program implies that paying the full rate for any session would make it difficult for an individual to pay their basic monthly living expenses.

I believe I qualify for this program. I know someone who might be interested in learning about this program.