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.

You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose.

Full Name

First NameMiddle NameLast Name

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Birth Date

MonthDayYear

Phone Number

Format: (000) 000-0000.

E-mail

example@example.com

Emergency Contact

Phone Number

Format: (000) 000-0000.

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

5. At what time of day is the pain at its worse?

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 therapeutic 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. In what position do you most often wake up?

Other

15. Are you currently seeing any other healthcare professional?

Please check any symptoms that apply to you and indicate right or left when applicable:

Head

Neck

Shoulders

Arms & Hands

Mid-Back

Low Back

Hip

Legs and Feet

Massage Policies: Client services and chart information are confidential. Written authorization is required from you to release any information. • Please turn off your cell phone for optimal relaxation • Please reschedule your session if you are more than 15 minutes late • 48-hour cancellation notice is required or your deposit will not be redeemed. • You will be draped and at no time will genitalia or breast tissue is exposed • You will have a consultation with your therapist to discuss your session • Should the session require, after your therapist has left the room, or turned around you may disrobe to your comfort level and covered with what was provided • I understand that my therapeutic massage therapist or I 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 therapeutic massage therapists do not diagnose illness, disease, any physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals, or perform joint mobilization. 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 therapeutic massage as a form of therapy. I understand that the treatment given is designed to address the care and prevention of myofascial pain and dysfunction. I also understand that at any time I feel pain or discomfort during the session, I will immediately inform my therapeutic 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 pose a threat to my health and/or physical well-being and I hold harmless Sinai Wellness Care 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