CLIENT INTAKE FORM

First Name*

Last Name*

Phone Number

Area CodePhone Number

Date of birth*

Date

Referred by*

Street Address

City

State

Zip Code

Emergency Contact Name*

Emergency Phone*

Area CodePhone Number

Date of initial visit*

Date

Have you had a professional massage before?*

Yes (Date of last treatment)No

How would you rate your general health?*

ExcellentGoodFairPoor

List current medications & the conditions they are treating *

List any major accidents or surgeries (including dates)*

Please tell us about any allergies or hypersensitivities*

Circle Areas of Concern

HEAD NECK

CARDIOVASCULAR

RESPIRATORY

SKIN & INFECTIONS

NERVOUS SYSTEM

MUSCULOSKELETAL SYSTEM

REPRODUCTIVE

PregnantGiven birthGynecological problems

OTHER CONDITIONS

Are you sensitive to fragrance?

YesNo

Are you sensitive to lights?

YesNo

Are you sensitive to sounds?

YesNo

PLEASE TAKE A MOMENT TO CAREFULLY READ THE FOLLOWING INFORMATION AND SIGN WHERE INDICATED. IF YOU HAVEA SPECIFIC MEDICAL CONDITION OR SPECIFIC SYMPTOMS, MASSAGE/BODYWORK MAY BE CONTRAINDICATED. A REFERRAL FROM YOUR PRIMARY CARE PROVIDER MAY BE REQUIRED PRIOR TO SERVICE BEING PROVIDED.

It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of
appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status.

If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage or bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage/ bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly.

I understand that energy healing is a simple, gentle, hands on healing technique that is used for stress reduction and relaxation. I understand that energy practitioners do not diagnose conditions nor do they prescribe or perform medical treatment, prescribe substances, nor interfere with the treatment of a licensed medical professional. I understand that energy healing does not take the place of medical care. It is recommended that I see a licensed physician or licensed health care professional for any physical or psychological ailment I may have. I understand that energy healing can complement any medical or psychological care I may be receiving. I also understand that the body has the ability to heal itself and to do so, complete relaxation is beneficial. I acknowledge that long term imbalances in the body sometimes require multiple sessions in order to facilitate the level of relaxation needed by the body to heal itself.

I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner's part should fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. I also understand that if I attempt to uncover my groin or expose my genitals or buttocks, that the massage will be stopped and will still be liable for payment of the session.

Signature*

Printed Name*

Date*

Date