Massage by Melinda - New Client Intake Form
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Age
*
Have you ever had a professional massage?
*
I have never had a professional massage.
Within the month
Within the year
Within five years
I can't remember, but I've had one at some point.
Were you referred by anyone?
*
Is there anything that you do not like about massage.
*
What is your primary reason for booking a massage?
*
Please list any medications / herbs / vitamins and corresponding dosages that you currently take.
*
Please list any physical activities you perform regularly.
*
Please describe any recent events of injury or accident.
*
Please list any previous major / minor surgeries.
*
Please check all that currently apply to you.
*
I have no health issues
Headaches
Vision Conditions
Sinus Problems
Jaw Pain
Fatigue
Depression
Infectious Disease
Sleep Difficulties
Skin Conditions
Chronic Pain
Muscle Pain
Joint Pain
Sprains / Strains
Cancer / Tumors
Diabetes
Scoliosis
Arthritis
Tendonitis
Varicose Vein
Blood Clots
High / Low Blood Pressure
Pregnant
Endometrioses
Painful Menstruations
Prostate Conditions
Other
Massage therapy is not a substitute for medical examination or diagnosis. It is recommended that I see a physician for any physical ailment that I may have. I understand that the massage therapist does not prescribe medical treatments or pharmaceuticals and does not perform any spinal adjustments. I am aware that if I have any serious medical diagnosis, I must provide a physician’s written consent prior to services. The licensee shall drape the breasts of all female clients and not engage in breast massage of female clients unless the client gives written consent before each session involving breast massage. Draping of the genital area and gluteal cleavage will be used at all times during the session for all clients. If the client is uncomfortable for any reason, the client may ask the licensee to end the massage, and the licensee will end the session. The licensee also has a right to end the session if uncomfortable for any reason.
*
I have read, understand, and agree to all parts of this statement.
New Client Signature
*
Date
*
/
Month
/
Day
Year
Submit
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