KMM Client Intake Form

Kentuckiana Mobile Massage Client Intake Form

Please complete this form to help us provide the safest and most effective massage therapy session for you.
Client Information
Full Name*

First NameLast Name
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth*

MonthDayYear
Date
Age*
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Occupation
Referred by
Health Information
YesNo
If yes, please list medications
YesNo
If yes, please list allergies
YesNo
If pregnant, how many months?
Due date (if pregnant)

MonthDayYear
Date
YesNo
If yes, please describe medical supervision/interventions
Areas of swellingAutoimmune disorderBack / neck problemsBleeding disordersBlood clotsBruise easilyBursitisCancerContagious conditionDecreased sensationDiabetesFibromyalgiaHeadachesHeart conditionHypertensionKidney diseaseMultiple sclerosisNeurological conditionNeuropathyOsteoarthritisOsteoporosisPhlebitisSciaticaSeizuresStrokeTendinitisTMJ disorderVaricose veinsVertigo / dizziness
YesNo
If yes, where?
YesNo
Which joint(s)?
YesNo
If yes, please describe
Please describe any other injuries or health conditions
Massage Information
YesNo
How recently was your last massage?
RelaxationSpecific problem
If specific problem, please describe
LightMediumFirm
Signatures
Client Signature*
Client Signature Date*

MonthDayYear
Date
Therapist Signature
Therapist Signature Date

MonthDayYear
Date
Should be Empty:

Kentuckiana Mobile Massage Client Intake Form