Client Intake

Name
Phone (day)
(evening)
Address

Address

Street Address Line 2

City/State/Zip
DOB
Occupation
Employer
Email
example@example.com
Primary Physician
Emergency Contact
Relationship
Phone
How did you hear about us?
Medical Information
Are you taking any medications?

yes no
If yes, please list name and use
Are you currently pregnant?

yes no
If yes, how far along?
Any high risk factors?
Do you suffer from chronic pain?

yes no
If yes, please explain
What makes it better?
What makes it worse?
Have you had any orthopedic injuries?

yes no
If yes, please list
Piease indicate any of the following that apply to you.

Cancer Fibromyalgia Headaches/Migraines Stroke Arthritis Heart Attack Diabetes Kidmey Dysfunction Blood Clots High/Low Blood Pressure Numbness Joint Replacement(s) Neuropathy Sprains or Strains
Explain any conditions you have marked above
Massage Information
Have you had a professional massage before?

yes no
What type of massage are you seeking?

Relaxation Therapeutic/Deep Tissue
Other
What pressure do you prefer?

Light Medium Deep
Do you have any allergies or sensitivities?

yes no
Please explain
Are there any areas (feet, face, abdomen, etc.) you do not want massaged?

yes no
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

Clear
Date

Month Day Year
Date
Therapist Signature

Clear
Date

Month Day Year
Date
Should be Empty:

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