Get The Knots Out - New Massage Client Intake Form

New Massage Client Intake Form

Please fill out completely
Contact Information
Full Name
Date of Birth

MonthDayYear
Date
Address

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State/Zip
Email
example@example.com
Home Phone
Cell Phone
Work Phone
Occupation
Referred by
Emergency Contact
Emergency Contact Phone
Physician/Primary Care Doctor
Doctor Phone
Do I have permission to contact your doctor regarding your care?

YesNo
Is this massage/bodywork medically necessary (is it for a medical condition, injury or surgery)?

YesNo
Do you have a physician referral/prescription?

YesNo
Massage / General Information
What type of massage are you seeking?

RelaxationTherapeutic/Deep Tissue
Have you ever received professional massage/bodywork before?

YesNo
If yes, how often do you get massages?
What type of pressure do you prefer?

LIghtMediumFirm
Are you sensitive of touch/pressure in any area (ticklish) and, if so, where?
Are you allergic or sensitive to any oils (essential oils, nut oils, scents)? If yes, list the details
Are you pregnant? If yes, how far along are you?
List current medications & the conditions they are treating
List any major accidents or surgeries (including dates)
Rate your Stress level on an average day

1

2

3

4

5

6

7

8

9

10

1 is Low, 10 is High
Rate your Pain level on an average day

1

2

3

4

5

6

7

8

9

10

1 is Low, 10 is High
Rate your Energy level on an average day

1

2

3

4

5

6

7

8

9

10

1 is Low, 10 is High
How did your symptoms begin and when did they start?
What have you done for relief?
Do your symptoms interfere with your activities of daily living (sleep, work, childcare, exercise)?

YesNo
Please list and prioritize your current symptoms/issues (pain, stress, numbness/tingling, swelling, stiffness, etc.)
Health History
Check any of the following health conditions you currently have (If you are unsure, please ask). Please answer honestly, as massage may not be indicated for these conditions.

Blood clotsInfectionsCongestive heart failureContagious diseasesPitted edemaShinglesChicken poxTransmitted diseasesNone of the above
Health Conditions

Provide details, including treatment received, in the section below.

	Never had	Had in the past	Currently have
Muscle Pain or Stiffness
Joint Pain or Stiffness
Numbness or Tingling
Sciatica Pain
Swelling
High or Low Blood Pressure
Stroke or Heart Attack
Varicose/Spider Veins
Shortness of Breath or Asthma
Neurological Issues such as Parkinson's or MS
Digestive conditions (e.g. crohn's, IBS)
Ringing in the Ears
Dizziness
Epilepsy / Seizures
Cancer
Headaches or Migraines
Gas, Bloating, Constipation
Kidney Disease or Infection
Arthritis (Rheumatoid, Osteoarthritis)
Osteoporosis, Degenerative Spine or Disk Disease
Scoliosis
Broken Bones
Diabetes
Endocrine / Thyroid Conditions
Depression or Anxiety
Memory Loss, Confusion or Easily Overwhelmed
Allergies

Provide details, including treatment received, for any conditions you noted above
Please read and check the boxes on the following statements
I understand the massage/bodywork I receive is provided for the purpose of relaxation, stress relief and the relief of muscular tension. If I experience pain or discomfort during the session, I will immediately inform my therapist so the pressure/strokes can be adjusted to my level of comfort. I will not hold my therapist responsible for any pain or discomfort I experience during or after the session.*

I understand
I understand the services offered today are not a substitute for medical care. I understand my therapist is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat physical or mental illness.*

I understand
I affirm that I have notified my therapist of all known medical conditions and injuries. I agree to inform the therapist of any changes in my health and medical condition. I understand there shall be no liability on the therapist's part should I forget/fail to do so.*

I affirm
I understand that massage is entirely therapeutic and non-sexual in nature, and any illicit or sexually suggestive remarks or advances made by me (the client) will result in immediate termination of the session. I also understand I will be liable for payment of the entire session should an incident occur.*

I understand
Massage therapy involves the use of touch, and may at times include the use of lotions or creams. Coming to your massage therapy session with a clean body is imperative for the health and safety of both the client and massage therapist. Personal hygiene is mutually respected on both the part of the client and the massage therapist. Should either part fail to uphold their hygiene responsibilities, service for that sessions will be postponed.*

I understand
Massage Session Basics
- Please arrive at least at least 5 minutes before your scheduled appointment time to allow time to undress and get on the table to enjoy a relaxed and unhurried experience.

- Prior to your massage, please remove all jewelry and pull long hair back with a clip or band.

- In general, massage is given while you are unclothed. However, you may choose to wear an undergarment or a swimsuit. You will be covered with a top sheet throughout your session. Only areas of the body that are currently being treated will be exposed. The breast and genital areas will always remain draped and are never massaged. This is your massage and you should feel as comfortable as possible.

- Feel free to ask your therapist any questions before, during, or after the session. Your therapist is a highly trained professional and will be happy to make you feel informed and comfortable.
Credit Card Information for New Clients
I understand that I am required to provide valid credit card information to book my first appointment. I will provide this credit card info over the phone when making the appointment. Once done, my first appointment day/time will be confirmed. My card will be charged in full for the time booked only if I do not show up for my scheduled appointment (no-show) or do not give more than 24 hours notice before my appointment.*

I understand
Signature

Use your mouse, touch pad or touch screen to sign your name in the field
By signing below, I hereby waive and release my therapist from any and all liability, past, present, and future relating to massage therapy and bodywork.*

I agree
By signing below, I agree to the following statement: I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time.*

I agree
Signature

Clear
Date*

MonthDayYear
Date
Should be Empty:

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

New Massage Client Intake Form

Contact Information

Massage / General Information

Health History

Health Conditions

Please read and check the boxes on the following statements

Massage Session Basics

Credit Card Information for New Clients

Signature