New Client Intake Form

1
Indicate by marking any specific areas on the body you would like the massage therapists to concentrate on BLACK and the areas with pain BLUE by drawing on the image and the areas you want to avoid in RED* This field is required.
2
Please enter your birthday below* This field is required.To quickly change the birth year tap on the Month and Year on the calendar
Month
Day
Year
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Must read all before you can agree to the terms & conditions* This field is required.
4
Please print your full name below before your signature * This field is required.
5
Please sign your signature below on the line* This field is required.
Clear
6
Form Signature Date and Time* This field is required.This is the date and time the form was signed.
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7
The Location Form Was Signed* This field is required.
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Other
Country
8
Please enter your name* This field is required.
First Name
Middle Name
Last Name
9
Please enter your main contact number* This field is required.
10
That number is my* This field is required.
My home number (landline)
My cell Phone
My work number
Someone else's number
Other
11
Please enter your E-mail* This field is required.
12
What's your gender:* This field is required.
Male
Female
Other
13
What's your relationship status* This field is required.
I'm Single
Have a Life Partner
I'm Divorced
I'm Separated
I'm getting a Divorce
Soon to be Widowed
It's complicated right now
I'm Widowed
I'm Engaged
I'm Married
Other
14
Do you live local?* This field is required.
YESNO
15
Enter your mailing address* This field is required.
Street Address
City
State
Zip Code
United States
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
16
How long have you lived at this address?0=less than a year
17
Please enter your emergency contacts name?* This field is required.
18
What's your relation to the emergency contact?* This field is required.
My mother
My father
My sister
My brother
My grandma
My stepmother
My stepfather
My friend
My grandfather
A close friend
My mother in law
My father in law
My legal guardian
My power of attorney
My boyfriend
My girlfriend
My husband
My wife
My fiancee
My son
My daughter
Other
19
What's your emergency contact number* This field is required.
20
Have you ever had a professional massage service before?* This field is required.
YESNO
21
Have you seen a local massage therapist in the area before within a 30-mile radius?* This field is required.
YESNO
22
Have you seen a massage therapist outside a 30-mile radius?* This field is required.
YESNO
23
How many massage services have you had before all together total?* This field is required.This can be a rough estimate or exact. If you have had more than 100 massages then use the '100+'
24
What types of massage services have you had before?* This field is required.Choose all the ones that apply
Deep Tissue
Swedish
Cranial Sacral
Chair Massage
Shiatsu
Reflexology
Sports Massage
Facial Massage
Hot Stone
Other
25
How was your experience with any of your previous massage services or services?* This field is required.
It was Good
It was Bad
It was Alright
It was meh (Neutral)
I Don't Remember
Other
26
If you could have changed anything about the experience or experiences to have made the perfect what would it be?* This field is required.
27
Do you have trouble laying flat on your back for long periods of time?* This field is required.
YESNO
28
Do you have trouble laying flat on your stomach for long periods of time?* This field is required.
YESNO
29
Do you have trouble laying on your sides for long periods of time?* This field is required.
YESNO
30
How do you usually sleep?* This field is required.Choose all that apply
on my right side
on my left side
on my back
on my stomach
with my left leg bent up
with my right leg bent up
with a medical device(s)
with a pillow between their legs
Other
31
14. In what position do you most often wake up?* This field is required.Choose all that apply5
Back
Side
Stomach
Other
32
Are you sensitive to scents or smells?* This field is required.
YESNO
33
Please list the scents or smells you are sensitive to?* This field is required.Please spare no details. We want to make sure we have all the necessary information for your massage therapist to best recommended their professional option
34
Do you have sensitive skin?* This field is required.
YESNO
35
Tell us more about your sensitive skin so we can make sure we avoid agitating your skin* This field is required.Please spare no details. We want to make sure we have all the necessary information for your massage therapist to best recommended their professional option
36
Do you have any allergies to oils, lotion or onement's?* This field is required.
YESNO
37
Please tell us more about the lotions, ornaments or oil's that you have an allergy to below* This field is required.Please spare no details. We want to make sure we have all the necessary information for your massage therapist to best recommended their professional option
38
Have you ever had a injury to the spine or head concussion?* This field is required.
YESNO
39
Please list all injuries, surgeries with dates, the recovery process and any complications.* This field is required.Please spare no details. We want to make sure we have all the necessary information for your massage therapist to best recommended their professional option. Yes this is all past surgeries not just spine or head concussion.
40
Are you currently under medical supervision?* This field is required.
YESNO
41
Please enter your doctor's name, location, what you see them for and the date of your last visit in one line.* This field is required.Tap ADD MORE to enter another doctor and their information in the next.
42
Have you ever been treated by a chiropractor?* This field is required.
YESNO
43
Is the chiropractor you've been seeing local?
YESNO
44
Is it Ingram right down the road?
YESNO
45
Did your most recent chiropractor take X-rays?* This field is required.
YESNO
46
Do you have any issues with your spine?* This field is required.Choose all that apply
Cervical Neck C1
Cervical Neck C2
Cervical Neck C3
Cervical Neck C4
Cervical Neck C5
Thoracic Chest T1
Thoracic Chest T2
Thoracic Chest T3
Thoracic Chest T4
Thoracic Chest T5
Thoracic Chest T6
Thoracic Chest T7
Thoracic Chest T8
Thoracic Chest T9
Thoracic Chest T10
Thoracic Chest T11
Thoracic Chest T12
Lumbar Low Back L1
Lumbar Low Back L2
Lumbar Low Back L3
Lumbar Low Back L4
Lumbar Low Back L5
Lumbar Low Back L6 (Rare)
Coccyx Tailbone CX1
Coccyx Tailbone CX2
Coccyx Tailbone CX3
Other
47
Do you bruise easy?* This field is required.
YESNO
48
Are you taking any of the following?* This field is required.
Pain Killers
Nerve Pills
Insulin
Muscle relaxer
Stimulants
Blood thinners
other
49
Please list any other medications you are taking and reason below* This field is required.
50
Do you have any of the following medical conditions or procedures?* This field is required.
Hepatitis
Hernias (Venereal Disease etc.)
Alcohol abuse
Drug abuse
Artificial valves
Mitral valve prolapse
Congenital heart defect
Heart Surgery
Pacemaker
Heart attack
Stroke
HIV+
AIDS
ARC
Shingles
Cancer
Glaucoma
Anemia
Diabetes
High blood pressure
Low blood pressure
Psychiatric problems
Rheumatic fever
Severe/Frequent Headaches
Kidney Problems
Ulcers
Colitissemia
Fainting
Seizures
Epilepsy
Sinus Problems
Emphysema
Asthma
Tuberculosis
Difficulty breathing
Chemotherapy
Lower Back Problems
Artificial bones/joints/implants
Arthritis Contagious skin conditions
Open sores or wounds
Easy Bruising
Recent Fracture
Recent accident or injury
Recent surgery
Current fever
Swollen glands
Circulatory Disorder
Varicose veins
Phlebitis
Epilepsy
Decreased sensation
Fibromyalgia
TMJ disorder
Carpal Tunnel Syndrome
Tennis Elbow
Multiple sclerosis
Any broken bones ever
Golfers elbow
Bursitis
Numbness
Tinging
Loss of sensation
Shingles
Seizures
Sciatica
Digestive issues
Immune systems issues
Reproductive issues
Menstrual issues
Atherosclerosis
Current cancer diagnosis
Psychologist or Psychotherapists
Eating disorders
Contact lenses
Wear glasses
Currently Pregnant
Past Pregnancy
Nursing
Miscarriage
Forced Miscarriage
Selective Abortion
Forced Abortion
None
Other
51
For each choice please list more information on each line* This field is required.Example Line One: Cancer diagnosed 4/3/1999
52
Have you received a covid vaccine or have had any shot or injection of any kind in the past month? Example: Botox, fillers. The reason we ask is to make sure it is dually noted in your profile so that we can avoid that areas if it is still tender.
YESNO
53
Have you had any hormone treatments or replacements recently?
YESNO
54
Are you currently in any pain?
YESNO
55
Rate Pain from 0 to 100 being no pain at all and 10 being the worst pain you have ever felt
56
What's your main focus for the session?
Relaxation
Pain Relief
Both but more Relaxation
Both but more Pain Relief
Other
57
Which do you prefer?
Massage oils
Massage lotions
I don't know
Either is fine
Other
58
Do you have any special music request for the session?
YESNO
59
Which would you prefer?Choose all that apply or let us know what specifically you would like
Relaxing instrumental NO LYRICS
Relaxing acoustic cover songs WITH LYRICS
Relaxing natural sounds (waves, rain etc)
Whichever is fine with me
Other
60
Would you like to focus on the head during the session?
YESNO
61
HeadChoose all the areas you would like to focus on the head
Temples
Forehead
Top of head
In the eyes
Entire head
Base of skull
Dizziness
Fainting
Light-headedness
Pain in ears
Ringing in ears
Other
62
Would you like to focus on the neck during the session?
YESNO
63
Neck Choose all the areas that would apply to your 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
Other
64
Would you like to focus on the shoulders during the session?
YESNO
65
ShouldersChoose all the areas you want to focus on and that apply
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
Other
66
Would you like to focus on the Mid-Back during the session?
YESNO
67
Mid-BackChoose all the areas that would apply to your Mid-Back
Mid-back pain
Pain between shoulder blades
Pain up/down back
Pain across mid back
Pain with breathing
Other
68
Would you like to focus on the Hips during the session?
YESNO
69
HipChoose all the areas that would apply to your Hips
Pain in buttocks
Pain in buttocks when standing
Pain buttocks in buttocks when sitting
Pain on side of hip
Pain deep in hip joint
Pain on sit bone
Diagnosed bursitis
Diagnosed arthritis
Other
70
Would you like to focus on the Low-Back during the session?Choose all the areas that would apply to your Low Back
YESNO
71
Low BackChoose all the areas that would apply to your 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
Other
72
Would you like to focus on the Legs or Feet during the session?Choose all the areas that would apply to your Legs or Feet
YESNO
73
Legs and FeetChoose all the areas that would apply to your 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
Other
74
Would you like to focus on the Arms and Hands during the session?Choose all the areas that would apply to your Legs or Feet
YESNO
75
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
Other
76
Are you feeing pain in any of the areas of focus ? If so what type?
Sharp shooting
Burning sensation
Muscle Spams
Twitching
Numbness
Tingling
Muscle soreness
Tension
Other
77
4. Frequency - please select the most accurate* This field is required.
Constant
Off/On
At Rest
With Activity
Other
78
5. At what time of day is the pain at its worse?* This field is required.
Morning
Afternoon
Evening
During Sleep
Other
79
Have you ever injured these areas before?
YESNO
80
Please list any and all recurring injuries past to presentIn each line enter the dates and more information then ADD MORE to add another injury or incident
81
Have you ever been in an accident?(automobile, work, falls, etc.) ?
YESNO
82
Please list all the past accidents in each lineOn each line enter the date and type of injury with related treatment received for this injury and then tap ADD MORE to add more past accidents
83
9. Have you ever received therapeutic massage for a specific problem or injury?If yes, please give date of last massage.
84
Are you only wanting to focus on the areas indicated through the whole session or did want to incorporate it into a full body?
Target those areas only
Incroptae them into a full body
Your profession option
Other
85
Are there any areas on the body you want to avoid?On each line enter the date and type of injury with related treatment received for this injury and then tap ADD MORE to add more past accidents
YESNO
86
List the areas you want to avoid
87
Did you want to incorporate target stretching into the session?
YESNO
88
Which stretching did you want to incorporate into the session?
89
10. Is there anything that you do that creates, increases or decreases pain? * This field is required.If yes, please explain.
90
What is your occupation?Please list each occupation and add more if need be.
91
What are the physical duties required of your occupation?Please list each physical duty required on each line
92
What activities/hobbies do you enjoy?
93
Please list exercise and stress reduction activities (including frequency).
94
Policy, Procedure & Fee's* This field is required.
95
Signature* This field is required.
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