Client Intake

Name
Phone (day)
Format: (000) 000-0000.
Address

Address

Street Address Line 2

City/State/ZipState / Province

Postal / Zip Code
DOB
Occupation
Email
example@example.com
Emergency Contact
Relationship
Phone
Format: (000) 000-0000.
How did you hear about us?
Medical Information
Are you taking any medications?
If yes, please list name and use
Are you currently pregnant?
If yes, how far along?
Any high risk factors?
Do you suffer from chronic pain?
If yes, please explain
What makes it better?
What makes it worse?
Have you had any orthopedic injuries?
If yes, please list
Piease indicate any of the following that apply to you.
Explain any conditions you have marked above
Massage Information
Have you had a professional massage before?
What type of massage are you seeking?
Other
What pressure do you prefer?
Do you have any allergies or sensitivities?
Please explain
Are there any areas (feet, face, abdomen, etc.) you do not want massaged?
Please explain
What are your goals for this treatment session?
Please list any areas of discomfort
By signing below you agree to the following. I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time.
Client Signature
Date

MonthDayYear
Date
Therapist Signature
Date

MonthDayYear
Date
Should be Empty: