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 NameLast Name

Date*

Date

Birth Date

DayMonthYear

Phone Number*

E-mail*

example@example.com

Address*

Street Address

City

Post CodeCountry

Emergency Contact*

Phone Number*

Occupation

Medications

Allergies

1. List Areas of Discomfort or Pain*

History of Pathology

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?

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

• 24 hour cancellation notice is required to avoid a £30 cancellation fee

• You will be draped and at no time will genitalia or breast tissue be exposed

• You will have a consultation with your therapist to discuss your session

• Ensure you wear loose fitting clothes and a normal bra.

• 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 treatment given is designed to address the care and prevention of myofascial pain and dysfunction.

I also undersand 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 post a threat to my health and/physical well being and I hold 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.

Date

Signature*

Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.