Massage Therapy Client Intake

Client Intake Form All information is held strictest confidence. At no given point is information disclosed or shared without client’s written consent.
Full Name *

First Name Middle Name Last Name
Date *

Day Month Year
Address *

Street Address

Street Address Line 2

City

Postal / Zip Code
Birth Date

Day Month Year
Phone Number *
E-mail *
Emergency Contact *
Phone Number *
COVID-19 Vaccination Status *
As per the COVID-19 Protection Framework legislation, only vaccinated persons with a current My Vaccine Pass will be eligible for treatment.
Occupation
Medications
Allergies
History of Pathology
1. List Areas of Discomfort or Pain *
2. Describe Onset of Discomfort or Pain
3. Rate of Pain Today
4. Frequency - please select the most accurate

Constant Off/On At Rest With Activity
5. At what time of day is the pain at its worse?

Morning Afternoon Evening During Sleep
6. Have you ever injured this area before?
7. Have you ever been in an accident (automobile, work, falls, etc.) ? *
8. List all related treatments received for this injury.
9. Have you ever received remedial massage for a specific problem or injury?
Was the treatment used effective?
10. Is there anything that you do that creates, increases or decreases pain?
11. What are the physical duties required of your occupation?
12. What activities/hobbies do you enjoy?
13. Please list exercise and stress reduction activities (including frequency).
14. Are you currently seeing any other healthcare professional?
Please check any symptoms that apply to you and indicate right or left when applicable:
Neck

Stiffness Pain at neck shoulder junction Pain when turning head Pain with side to side movements Neck feels out of place Muscle spasm in neck Gliding/Grating sound with neck movement Diagnosed bone spurs Diagnosed disc herniation
Shoulders

Pain in shoulder Front Back Side Pain deep in shoulder joint Diagnosed bursitis Diagnosed Arthritis Can't raise arm above shoulder level Can't raise arm over head
Arms & Hands

Pain in upper arm Pain in forearm Pain in wrist Pain in fingers Sensation of pins & needles in arm Sensation of pins & needles in fingers Fingers go to sleep Hands cold Swollen joints in fingers Sore joints in fingers Diagnosed arthritis Loss of grip strength
Mid-Back

Mid-back pain Pain between shoulder blades Pain up/down back Pain across mid back Pain with breathing
Low Back

Low back pain Low back pain is worse when working Low back pain is worse when lifting Low back pain is worse when stooping Low back pain is worse when standing Low back pain is worse when sitting Low back pain is worse when bending Low back pain is worse when coughing Pinched nerve in low back Low back feels out of place Pain up/down low back Pain across low back Diagnosed disc herniation
Hip

Pain in buttocks Pain in buttocks when standing Pain in buttocks when sitting Pain on side of hip Pain deep in hip joint Pain on sit bone Diagnosed bursitis Diagnosed arthritis
Legs and Feet

Pain down RIGHT leg Pain down LEFT leg Pain down BOTH legs Leg cramps Pin & Needles in RIGHT leg Pin & Needles in LEFT leg Numbness in RIGHT leg Numbness in LEFT leg Numbness in RIGHT foot Numbness in LEFT foot Numbness in toes Feet feel cold Cramps in RIGHT foot Cramps in LEFT foot Swollen RIGHT ankle Swollen LEFT Ankle Swollen RIGHT foot Swollen LEFT foot Pain in RIGHT Foot Pain in LEFT Foot Pain in RIGHT knee Pain in LEFT knee Diagnosed Arthritis
Massage Policies: Client services and chart information are confidential. Written authorization is required from you to release any information.

• 24 hour cancellation notice is required to avoid being charged for your session

• You will be draped and at no time will genitalia or breast tissue be exposed

• You will have a consultation with your therapist to discuss your session

• After your therapist has left the room, you may disrobe to your comfort level

• You understand that the massage therapist or you may end the session at any time for any reason

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

Client Agreement: I understand that remedial massage therapists do not diagnose illness, disease, any physical or mental disorder, nor do they prescribe medical treatment, or pharmaceuticals. 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 remedial 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 during the session, I will immediately inform my massage therapist so they adjust. I have stated my pertinent medical conditions, and will update the massage therapist of any changes in my health status. I understand that my failure to do so may post a threat to my health and/physical well being and I hold harmless Pure Touch Therapy and my therapeutic massage therapist from any liability whatsoever arising from failure on my part. By my electronic signature below, I agree to the massage policy and client agreement above.
Signature *

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

Now create your own Jotform - It's free! Create your own Jotform