Spa Client Intake Form

Spa Client Intake Form
Patient Data
Patient Name

First NameLast Name
Age
Birthday

MonthDayYear
Date
Gender
Occupation
Referred by
Phone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Person

First NameLast Name
Emergency Contact Phone Number
Relationship to the Patient
Physician Name

First NameLast Name
Physician Phone Number
Please enter a valid phone number.
Reason for visit:
How would you rate your general health?

PoorFairGoodExcellent
Have you ever had a professional massage?

NoYes
Last time?
Describe any treatment you've received for these particular issues
Describe your treatment goals
Are you wearing any eye contact lenses?

YesNo
Medical / History Data
Cardiovascular
Do you have any of the following conditions?

Congestive heart failureHemophilliaHeart diseasePacemakerLow blood pressureStrokePoor circulationFamily HistoryVaricose VeinsHeart attackEmbolismHigh blood pressureSpinal Cord IssuesPhlebitisThrombosis
Head & Neck

DizzinessHeadachesHearing lossMigrainesVision lossEar problemsJaw pain (TMJ)Heart attackVision problemsHigh blood pressure
Musculoskeletal

ArthritisTendonitisOsteoporosisMigrainesArtificial jointSugical pin/wireHeart attackBursitisHigh blood pressure
Respiratory

AsthmaEmphysemaTuberculosisSmokerChronic coughBronchitisSinusitisShortness of breath
Are you smoking? If yes, how many packs a day?
Reproductive

Given birthGynecological problems
Are you pregnant, breastfeed, or nursing? (Female)

YesNo
Skin

Bruise easilySkin irritationSkin conditionsSkin infections
Miscellaneous

AnxietyHIV/AIDSDiabetesCancerDigestive conditionsStressDepressionFibromyalgiaOther
Are you wearing any implantable medical devices? If yes, what are these devices?
Are you currently taking any medications? If yes, please list them below:
Were you previously hospitalized? If yes, please indicate when and why:
Did you undergo any surgery in the past? If yes, please indicate the name or location of the surgery:
How do you manage stress? Please elaborate:
Waiver
- Please read and sign:
  
  I understand that massage therapy is provided for stress reduction, relaxation, relief from muscular tension, and improvement of circulation and energy flow.
  
  If I experience pain or discomfort during the session, I will immediately inform my therapist so that 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 that today's services are not a substitute for medical care and that my therapist is not qualified to diagnose, prescribe, or treat physical/mental illness.
  
  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 and that there shall be no liability on the therapist's part should I forget to do so.
  
  • I understand that massage is entirely therapeutic and non-sexual in nature.
  
  By signing this release, I waive and release my therapist from any liability, past, present, and future, relating to massage therapy and bodywork.
Signature of the Patient

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Date

MonthDayYear
Date
Describe injuries, concerns, or issues to address+ causes and dates of occurrences
Should be Empty:

Spa Client Intake Form

Patient Data

Reason for visit:

Medical / History Data

Cardiovascular

Waiver