Client Intake Form: Massage Therapy and Assisted Stretching

Full Name

First NameLast Name

Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Do you give consent for the therapist to call, text, or leave a voicemail on the above listed phone number?

Date of Birth

Date

Emergency Contact Name

Emergency Contact Phone

Please enter a valid phone number.Format: (000) 000-0000.

Have you had a massage before?

What type of massage pressure do you prefer?

List your occupation and any hobbies.

This gives us an idea of areas you may be experiencing pain or tension in.

Are there any areas you would like the therapist to avoid?

Please list any allergies or sensitivities we should be aware of.

I.e. Nut allergy; strong fragrances

Please list any prescription or over-the-counter medicine, supplements, and herbals you currently take.

Which of the following cardiovascular conditions apply to you?

Which of the following head & neck conditions apply to you?

Which of the following musculoskeletal conditions apply to you?

Which of the following neurological conditions apply to you?

Which of the following respiratory conditions apply to you?

Which of the following reproductive conditions apply to you?

Which of the following skin conditions apply to you?

Which of the following miscellaneous conditions apply to you?

Are you in pain?

On a scale of 0 to 10, what is your pain level? 0=no pain 10=Extreme pain

Where is the pain located? How long have you had the pain? What makes it better?

Please read and sign:

I understand massage therapy is provided for stress reduction, relaxation, relief from muscular tension, and improvement of circulation and energy flow.

I understand today's services are not a substitute for medical care and my therapist is not qualified to diagnose, prescribe, or treat physical/mental illness.

If I experience any pain or discomfort during the session, I will immediately inform my therapist so that adjustments can be made to my comfort level. I will not hold my therapist responsible for any pain or discomfort I experience during or after the session.

I affirm 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 there shall be no liability on the therapist's part should I forget to do so.

I understand that massage or assisted stretching is entirely therapeutic and non-sexual in nature.

I understand full payment is required at the end of my session.

I have visited the therapist's website at https://www.unplugandunwindco.com to find additional information such as the cancellation policy, late arrival policy, parking information, etc.

By signing this form, I waive and release my therapist from any liability, past, present, and future, relating to massage therapy, bodywork, and assisted stretching.

Signature (Consent to treatment)

How did you hear about Unplug & Unwind Massage Therapy Studio?