Massage Therapy Client Intake

Myo And Relaxation Therapy

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.
Full Name*

First NameMiddle NameLast Name
Please pick one.*

I am a male.I am a female.
Phone Number*
Todays date

MonthDayYear
Date
Date of Birth

MonthDayYear
Date
E-mail address:*
How did you find our business.

GrouponWalk - inReferralInternet Search
Massage Policies:

Client services and chart information are confidential. Written authorization is required from you to release any information.

       • You can keep your phone ringer on if you want - it's ok with us.

       • You can be late and reschedule as often as you want, no problem (This is a no stress business)

       • You may disrobe to your comfort level, 100% nude under the covers is best for both customer and therapist.

       • I understand that my Myo & Relaxation therapist or I may end the session at any time for any reason

Client Agreement:

I understand that therapeutic MYO therapists do not diagnose illness, disease, any physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals.

I acknowledge that massage therapy is not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for that service.

It is my choice to receive therapeutic MYO treatments as a form of therapy.

I understand that treatment given is designed to address myo / muscle pain and stress.

I also undersand that if at any time I feel discomfort during the session, I will immediately inform the Myo therapist so they adjust the pressure.

I have stated my pertinent medical conditions, and will update the massage therapist of any changes in my health status.

I understand that my failure to do so may post a threat to my health and/physical well being and I hold harmless Myo therapist from any liability whatsoever arising from failure on my part.

By my electronic signature below, I agree to the massage policy and client agreement above.
Please note: What do you do the most all day?

Stand most of the day.Sit most of the day.Walk most of the day.All of the above.
Do you have high pain tolerance?

Yes, Some what high.Yes, Very high, I can ignore most of my pains.No, I have mostly tightness and some pain.No, I have Zero pain tolerance, and I know when I am hurting.
Which are you more?*

I am stressed moreI am in pain more
Are you more?

I am overweightI am normal weight.
Which of these apply to you?*

I exercise often.I eat correctly.I sleep well.I work often.I attempt wellness.
What is your occupation?*

TeacherNursePoliceEMSDoctorOther
Are you taking any Medications?*

Yes, I am but none of them affect blood sugars, or blood pressure,Yes, and I will list them in other.Yes,No - I am not taking medicationsOther
Please note: What hurts on your body most of the time?

Lower backGlutesNeckTop of shouldersHandsFeetLegsKneesElbowsBottom of head/ Hair Line area/ NeckMid back / shoulder blades areaUpper chest/ PecksAll of the above.
E Signature here /s/
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