New Client Intake Form
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Phone Number
-
Area Code
Phone Number
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Occupation
Emergency Contact
Emergency Contact Phone Number
-
Area Code
Phone Number
Are you currently under a physicians care for an acute or chronic illness?
Yes
No
If under a physician’s care, please explain
If yes, who is your health care provider and what is their contact information?
Have you ever received a massage before? If so, when?
How did you hear about me?
What are your goals for this session?
Health InformationPlease select all current conditions list all past conditions in bottom other box
Abdominal /digestiveproblems
Alllergies
Anxiety
Arthritis/tendonitis
Asthma or lung condition
Athletes foot
Blood Clots
Chronic pain
Circulatory problems
Constipation/diarrhea
Depression
Diabetes
Fatigue
Headaches and migraines
Hearing problems
Hernia
High Blood Pressure
Jaw pain/ TMJ
Low Blood Pressure
Muscle/bone injuries
Muscle/ joint pain
Numbness/tingling
Pregnancy
Rash/ Fungus
Sinus Problems
Sleep Difficulties
Spinal Disorder
Sprain/Strain
Tension/Stress
Vision Problems
Varicose veins
Other
Elaborate on noted areas above:
Please list areas of tension, stress and/or pain you wish to be addressed:
Please list any recent injuries or surgeries within the past 5 years:
Please list your stress-reduction activities, hobbies, exercise and/or sport participation:
Submit
Should be Empty: