Standard Client Intake Form

1
Full Name* This field is required.
First Name
Last Name
2
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
3
Primary Phone Number* This field is required.
Area Code
Phone Number
4
E-mail* This field is required.
5
Birthday* This field is required.
6
Primary Care Provider* This field is required.Name & Phone Number
7
Do we have permission to contact your primary care provider if consultation is required?* This field is required.
YESNO
8
Emergency Contact Name* This field is required.Name
9
Emergency Contact Phone Number* This field is required.
Area Code
Phone Number
10
Your Employer
11
Your Occupation* This field is required.
12
How did you hear about us?
Please Select
Please Select
Doctor / Midwife (if so, who?)
Doula (If so who)
Facebook
Website
Referral (if so, who?)
Other
Type of referral
Name of referral
13
Which, of any of the following are you experiencing?* This field is required.Choose as many as you need to
Anemia
Cancer (past or current)
Sciatica
Epilepsy
Skin Disorders or Rashes
Varicose Veins
Contagious Conditions
Arthritis
Bursitis
Autoimmune Disorder
Edema/Swelling
Diabetes
Headaches
TMJ
Plantar Faciitis
Scoliosis (mild or severe)
Separation of Abdominal Muscles
Low Blood Pressure
Muscle Sprain/Strain
Carpal Tunnel Syndrome
Allergies to Nut Oils
Recent Surgeries
Broken Bones
Fibromialgia
Lyme Disease
High Bood Pressure
Low Blood Pressure
Fever
Kidney Disease
Heart Disease/Complications
None
Other
14
Are you currently taking an medications?* This field is required.
YESNO
15
Please list and explain any medications you are taking
Huge
Large
Normal
Small
Ok
Ok
16
If you currently exercise, please list the nature and duration of your physical activity
17
Regarding your body size/stature:Please check any below that apply to you
Under 5' Tall
6' or Taller
None of the above
18
Preferred Pressure / Intensity* This field is required.A good massage is not so deep that you flinch or tense up, but deep enough that it feels good to you. GENERALLY SPEAKING, on a scale of 1-10, what depth of pressure/intensity feels perfect to you?
As a reference: 0 - light touch / 5 - moderate pressure / 10 - as deep as can be
19
How Time is Spent* This field is required.GENERALLY SPEAKING, Are there any areas you want me to skip entirely, either because you don't like it, or because you want to allocate more time elsewhere?
20
Please let me know anything that annoys you or leaves you disappointed in a massage session.(I'll make sure NOT to do these things!)
21
Do you currently have any specific areas of concern/tension?
22
Please tell me what you hope to accomplish during your session.* This field is required.
23
Please let me know the things you really LOVE in a massage(For example: "I really love my feet being worked on!")
24
Would you like to be added to our mailing list to receive updates and specials?
YESNO
25
Agree to Policies, Terms & Conditions?* This field is required. I have stated all my known medical conditions and take it upon myself to keep my therapist updated on changes to my physical health. I understand that any information exchanged during a session is kept confidential. If I am currently having or at any future point develop complications or serious conditions during and/or after my pregnancy, I will notify my massage therapist prior to my session, and will have a medical release for bodywork signed by my prenatal care provider before receiving massage therapy. I understand that massage therapy given here is for the purpose of stress reduction, relaxation, relief from muscular tension, or for increasing circulation, balance, body awareness and energy flow. I understand that the therapist does not diagnose illness, disease, or any other physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals, nor do they perform any spinal manipulations. I understand that massage therapy is not a substitute for prenatal care, medical examination and/or diagnosis and that it is recommended that I see a physician for any physical ailment and that I have regular prenatal care. CANCELLATIONS/RESCHEDULING: If I am not able to make a scheduled appointment, I agree to cancel or reschedule the appointment AT LEAST 24 hours in advance. I agree to pay $35 or 50% of the full session rate (whichever is greater) if I give less than 24 hours notice. If I am in labor, have a contagious illness, or have a sudden, unplanned health or personal emergency that will cause me to miss my appointment I agree to inform Portland Prenatal Massage immediately, but agree to the pay the cancellation fee unless Portland Prenatal Massage decides to grant an exception to my circumstance. I agree to pay the full session rate if I give 2 hrs notice or less, or if I miss an appointment without giving notice. I understand that payment is due at the time of service. I do forever release Julia Donaldson, DBA Portland Prenatal Massage from all liability of any nature whatsoever, whether past, present, or future for any injury or damage which may occur to myself or my family as a result of my receiving massage therapy and bodywork from this point forward. I agree to hold harmless and defend the practitioner of and from all actions, claims, or other legal or administrative action that has arisen or may arise directly or indirectly out of my participation in this therapy. I have completed this health form to the best of my knowledge. By agreeing to and submitting this form, I agree to abide by the polices, terms and conditions set forth and I realize these policies may change at any time without notice.
YESNO
26
Signature
Should be Empty: