Massage Therapy new patient 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.

Have you been overseas in the past 14 days?’ and/or ‘Have you been displaying any fever-like symptoms?’and/or "have you been in contact with anyone diagnosed with COVID-19"?

My massage therapist for today is:

Name

First NameLast Name

Date Of Birth

DayMonthYear

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

E-mail (for appointment reminders)

Occupation

Phone Number

Area CodePhone Number

Who can we thank for referring you?

Medications

Allergies

History of Pathology

Mark on the image your area of complaint

1. Current symptoms/location and duration or onset

2. History of presenting complaint (how it happened/position direction etc) 

3. Rate of Pain Today

4. Behaviour and type of pain

5. At what time of day is the pain at its worse?

6. Have you ever injured this area before?

7. Have you ever been in an accident (automobile, work, falls, etc.) ?

8. Is there anything that you do that creates, increases or decreases pain?

Please check any symptoms that apply to you and indicate right or left when applicable:

Headaches/migraines

Hip Pain

Do you have any of the following conditions/ symptoms ?

There are always some risks associated with any treatment. Below is a list of potential risks associated with massage therapy. The best way to reduce the chance of risk occurring is to answer all the questions about your health, fully and honestly. Please tick to acknowledge the risk and are happy to proceed:

Today's date:

DayMonthYear

Name

First NameLast Name

Signature

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