Intake Form

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 NameMiddle NameLast Name
Date*

MonthDayYear
Birth Date*

MonthDayYear
Phone Number*
Format: (000) 000-0000.
E-mail*
Emergency Contact*
Phone Number*
Format: (000) 000-0000.
Occupation*
Allergies? Aversions to scents/oils?
What would you like to get out of your session today?
Current Issues
1. List current areas of discomfort and pain and frequency (constant, off/on, at rest or sleep, or with activity).
2. Describe Onset of Discomfort or Pain
3. Rate of Pain Today
4. List all related treatments received for injury(ies). Were those treatments effective?
5. Do you experience numbness or tingling anywhere?
Pathology History
1. Have you ever broken any bones or had any other surgeries? Please list with years of incidents/procedures*
2. Have you ever been in an accident (automobile, work, falls, etc.)? Please list chronologically with descriptions of injuries acquired, if it still affects you today and how. *
EX: December 2013: slipped on stairs. Concussion and hip pain on left side. Had trouble walking for several weeks, but no current or lasting issues.
ChiropracticMassage TherapyAcupuncturePhysical TherapyRolfingOther
What has helped, and/or not helped, and why?
Please describe any treatments, activities, or interventions you've tried for your condition. Indicate what has been effective, what hasn't, and share your thoughts on why you believe each had the outcome it did.
4. Are you currently seeing any other healthcare professional?
Lifestyle
1. What are the physical duties required of your occupation or other responsibilities?
Consider tasks like lifting, standing, repetitive motions, or any physical demands specific to your role.
2. Is there anything that you do that creates, increases or decreases pain?
3. What activities/hobbies do you enjoy?
4. Please list exercise types and frequency.
BackSideStomachOther
6. Glasses of water per day:
7. Alcohol use (drinks per week):
Briefly describe your eating habits and how you relate to food.
Consider your usual diet, how emotions influence your eating, your meal patterns, and your overall mindset towards food.
Medical Reveiw
Medications?
DiabetesScoliosisLupusPsoriasis or eczemaPacemakerHearing aidsEpilepsyDrug or alcohol problemsC-section birth(s)Significant warts or growthsCardiac problemsPhlebitis (blood clots in leg)Significant scarsAthlete's footEasily bruise
DizzinessFaintingLight-headednessPain in earsRinging in earsHeadachesMigranesTMJ PainOther
StiffnessPain at neck shoulder junctionNeck feels out of placeMuscle spasmsGliding/Grating sound with neck movementDiagnosed bone spursDiagnosed disc herniationOther
StiffnessPain at neck shoulder junctionNeck feels out of placeMuscle spasmsGliding/Grating sound with neck movementDiagnosed bone spursDiagnosed disc herniationOther
Pain turning head to right, or bending towards right? Please identify location of pain (right or left side).
Pain turning head to left, or side-bending head to left? Please identify location of pain (left or right side).
Pain in front of shoulderPain on side of shoudlerPain in back of shoulderPain deep in shoulder jointDiagnosed bursitisDiagnosed ArthritisCan't raise arm above shoulder levelOther
Pain front of shoulderPain on side of shoulderPain in back of shoulderPain deep in shoulder jointDiagnosed bursitisDiagnosed ArthritisCan't raise arm above shoulder levelOther
Pain in upper armPain in forearmPain in wristSensation of pins & needles in armSensation of pins & needles in fingersFingers go to sleepCold handsDiagnosed arthritisLoss of grip strengthTennis elbowGolfer's elbowOther
Pain in upper armPain in forearmPain in wristSensation of pins & needles in armSensation of pins & needles in fingersFingers go to sleepCold handsDiagnosed arthritisLoss of grip strengthTennis elbowGolfer's elbowOther
Mid-back painPain between shoulder bladesPain up/down backPain across mid backPain with breathingOther
Low back painLow back pain is worse with activityLow back pain is worse when standingLow back pain is worse when sittingLow back pain is worse when coughingLow back pain is worse when laying downPinched nerve in low backLow back feels out of placePain up/down low backPain across low backDiagnosed disc herniationOther
Pain in buttocks when standingPain buttocks in buttocks when sittingPain on side of hipPain deep in hip jointPain on sit boneDiagnosed bursitisDiagnosed arthritisOther
Pain in buttocks when standingPain buttocks in buttocks when sittingPain on side of hipPain deep in hip jointPain on sit boneDiagnosed bursitisDiagnosed arthritisOther
Pain down legLeg crampsPin & Needles legNumbness in legNumbness in footNumbness in toesCold feetCramps footSwelling in foot or ankleSwelling in kneesFoot painKnee painDiagnosed ArthritisACL tearMCL tearPatellar tenditisMeniscus tearOther
Pain down legLeg crampsPin & Needles down legNumbness in legNumbness in footNumbness in toesCold feetCramps footSwelling in foot or ankleSwelling in kneesFoot painKnee painDiagnosed ArthritisACL tearMCL tearPatellar tendinitisMeniscus tearOther
Anything else you would like me to know about you?
Massage Policies

Confidentiality: All client information is confidential, and written consent is required to release any details. Myo-Fascial Length Testing (MFLT) may involve standing in underwear for assessment. Before-and-after photos, taken with your consent, document progress and will not be shared without your permission. You may opt out of photos anytime.

Phone Etiquette: Please turn off your cell phone during the session.

Cancellation Policy: A minimum of 24 hours' notice is required for cancellations. Cancellations made less than 24 hours before your scheduled session will result in a partial charge for the session as follows:

2-hour session late cancellation fee: $150
3-hour session late cancellation fee: $200

Session Attire: Women should wear tops with movable straps, and all clients should ensure their underwear allows for full access to the hips—ideally something you can comfortably give yourself a wedgie in. This attire is ideal for effective treatment, but your comfort is the priority—please wear what makes you feel at ease.

Session Termination: Either you or your Structural Medicine Specialist may end the session at any time for any reason.

Behavior Policy: Inappropriate behavior will result in the immediate termination of the session, and payment in full will still be required.

Client Agreement: I understand that Structural Medicine Specialists and Licensed Massage Therapists do not diagnose, prescribe, or perform joint mobilizations. These services do not replace medical examinations, and I acknowledge the recommendation to consult a physician for such needs. I choose to receive Structural Medicine therapy, focusing on myofascial pain and dysfunction. I agree to communicate any discomfort during sessions, disclose relevant medical conditions, and update my therapist on any health changes. I accept full responsibility for my health during therapy and release my therapist from liability related to undisclosed conditions. By signing below, I agree to these policies.
Signature*

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