activechiro.net - Massage and Bodywork Intake Form

Massage and Bodywork Intake Form
Client Information
Date

MonthDayYear
Date
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Day Phone
Please enter a valid phone number.Format: (000) 000-0000.
Evening Phone
Please enter a valid phone number.Format: (000) 000-0000.
Occupation
Date of Birth

MonthDayYear
Date
Emergency Contact Name
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Referred By
Email
example@example.com
Massage History / Session Information
Have you ever received professional massage?

YesNo
Date of last massage

MonthDayYear
Date
What result do you want from your massage sessions?
List any exercise activities. Include frequency:
Are you currently under the care of a health care practitioner?

YesNo
If yes, specify purpose:
List current medications and purpose:
Previous History

(Include year and treatment received)
Injuries/accidents/illnesses still affecting you:
Surgeries:
Please mark any of the following that you now have or have had.
Musculoskeletal

Bone or joint diseaseTendonitis / BursitisArthritis / GoutJaw pain (TMJ)LupusSpinal ProblemsOther:
Circulatory

Heart ConditionPhlebitis / Varicose VeinsBlood ClotsHigh / Low Blood PressureLymphedemaThrombosis / EmbolismOther:
Respiratory

Breathing difficulty/AsthmaEmphysemaAllergiesSinus ProblemsOther:
Allergies specify:
Nervous System

ShinglesNumbness / tinglingPinched NerveOther:
Reproductive

Pregnant: StageOvarian / menstrual problemsProstateOther:
Skin

AllergiesRashesAthletes footHerpes / cold soresOther:
Allergies specify:
Digestive

Irritable bowelSyndrome UlcersOther:
Other

Cancer / tumorsBladder / kidney ailmentDiabetesDrug / alcohol / caffeine / tobacco useChronic fatigueChronic painSleep disordersMigraines / headachesAnxiety / stress syndromeDepressionContact lenses ( hard or soft )Other:
Additional Client Remarks / Comments:
I have completed this form to the best of my knowledge and will inform the massage therapist of any change in my physical health.

I understand that a massage therapist can not diagnose illness, disease, or any other medical, physical, or emotional disorder, nor perform any spinal manipulations. I am responsible for consulting a qualified physician for any physical ailments that I have.

I understand that massage therapy is a therapeutic health aide and is non-sexual.

I understand that if the massage therapist starts a session late, they will make it up to me at the end of my session if possible, or will reduce my fee accordingly. I understand that if I arrive late, my session will end at the originally scheduled time so the client following me is not penalized.

I agree to give 24-hour notice for a scheduled session that I can not keep. I am aware that I may be charged the full fee for any missed sessions or for sessions that I do not give 24-hour notice to cancel or reschedule.
Signed
Date

MonthDayYear
Date
Should be Empty:

Massage and Bodywork Intake Form

Client Information

Massage History / Session Information

Previous History