New Client Intake Form
Client's Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Are you of the age 18 or older?
Yes, I am 18 years old or older
No, I am 17 years old or younger
Date of Birth
-
Month
-
Day
Year
Date
How did you find Enso Embrace?
Please specify if it was through referral
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
*
First/Last Name
Relationship
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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Basic Health Information
and your familiarity with massage therapy
How would you rate your general health (1-10)?
*
1 being the worst you've ever felt, and 10 being the best you've ever felt.
Do you have any allergies or hypersensitivities? Please include food items as well, as many oils contain food ingredients.
*
Please list any medications and conditions that they are treating.
*
Please list any major accidents, injuries or surgeries, as well as their estimated dates. Even older instances can create issues in the body.
*
How Familiar are you with massage?
*
I've never had a massage before
I've had a massage before but don't get them often
I get a massage when I need/feel like it
I get massages regularly or have in the past
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Other Health Questions
This information helps your therapist determine what kind of treatments are best for you.
How would you rate your usual levels of stress? (1-10)
*
Are there any repetitive motions you do throughout your day?
This can include motions done during hobbies, work or other daily activities. Ex: driving several hours, carrying heavy loads on the back or hip, standing several hours, holding an infant or motions done through sports and so on.
Are there areas of your body you feel you hold a lot of tension or pain?
Common Health Issues
Please select any that apply to you
Infection
*
None
Recently Sick
Recent Fever
HIV
Other
Integumentary (Skin)
*
None
Bruises
Burns
Cuts/Wounds
Acne
Eczema
Psoriasis
Cold Sores
Other
Skeletal
*
None
Osteoporosis
Broken/Healing Bones
Bone Fractures
Scoliosis
Kyphosis
Lordosis
Other
Muscular
*
None
Contusion
Muscle Ruptures
Sprain or Strain
Other
Organs
*
None
Hernia
Other
Cardiovascular
*
None
High Blood Pressure; On Medication
High Blood Pressure; No Medication
Blood Clot
Thrombosis
Varicose Veins
Phlebitis
Edema
Diabetes
Other
Nerves
*
None
Bell's Palsy
Other
Respiratory
*
None
Asthma
Irritable Lungs
Other
Do you have any Autoimmune Disorders? This Includes cancer, rheumatoid arthritis and much more.
*
Please let us know about any other health issues that may be important for your therapist to know about.
Are you currently pregnant, recovering from pregnancy or expecting to be pregnant soon?
Not Pregnant
Currently Pregnant
Recovering from Pregnancy
Expecting to be Pregnant Soon
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Recipient’s Signature
Submit
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