Client Intake Form

1
Name* This field is required.
First Name
Last Name
2
Date of birth* This field is required.
Date
Year
Month
Day
3
Email* This field is required.
example@example.com
4
Phone Number* This field is required.
Area Code
Phone Number
5
Are you interested in receiving updates on our special offers and sales? * This field is required.
YESNO
6
Have you ever had a professional massage?* This field is required.
YESNO
7
Physician Name and contact information?* This field is required.
8
How would your rate your general health?* This field is required.
Please Select
Please Select
Poor
Fair
Good
Excellent
9
Describe injuries concerns or issues to address, causes, and dates of occurrences
10
Describe any treatment you've received for these particular issues.
11
Describe your treatment goals
12
Health History: Cardiovascular
Congestive heart failure
Low blood pressure
Heart Diease
Poor circulartion
Varicose Veins
Embolism
Hempophilia
Pacemaker
Heart attack
High blood pressure
Phlebitis
Thrombosis
None
13
Health History: Head and Neck
Dizziness
Ear Problems
Headaches
Jaw Pain (TMJ)
Hearing Loss
Vision Problems
Migraines
Vision loss
None
Other
14
Health History: Musculoskeletal
Arthritis
Artificial joint
Bursitis
Osteoporosis
Surgical pin/wire
Tendonitis
None
15
Health History: Neurological
Epilepsy
Multiple Sclerosis
Numbness/Tingling
Sensory loss/change
Sciatica
Seizures
Vasovagal Response
None
16
Health History: Reproductive
Given Birth
Gynecological problem
Pregnant
None
17
Health History: Respiratory
Asthma
Bronchitis
Chronic Cough
Emphysema
Shortness of breath
Sinusitis
Smoker
Tuberculosis
None
18
Health History: Skin
Bruise easily
Skin Conditions
Skin Infections
Skin Irritations
None
19
Health History: Miscellaneous
Anxiety
Cancer
Depression
Diabetes
Digestive Conditions
Fibromyalgia
HIV/AIDS
Stress
None
20
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.
21
Cancellation & No - Show PolicyI agree to give a 24 hour notice if I need to cancel or reschedule an appointment. In the event of an emergency, I agree to inform my therapist as soon as I am able. I understand that it is at the therapist digression to charge a fee for a missed appointment.
YESNO
22
Date
Date
Month
Day
Year
23
Signature
Clear
24
Emergency contact: Name and Phone Number
25
Please read and sign:
YESNO
Should be Empty: