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Client Intake Form |
Please fill out all information as accurately and thoroughly as possible.
It is better that you give me what you consider too much information, rather than not give me enough information.
Name:� ______________________________
Address:� _____________________________
WK PHONE: (������ ) ____ - ______�� HM: (����� ) ____-______� CELL (����� )____-_____
Email/Web Site: ______________________
Date of Birth: ___________________
Hobbies (optional):
Emergency Contact and their relationship to you:
______________________________________� (������
)____-_____
Were you referred by anyone? ___________________________________
Have you ever received massage or bodywork before?� (If yes, how was it?)� ______________________________________________________________________________
What (specifically) would you like to receive from this massage?
______________________________________________________________________________
Would you like me to focus on or stay away from any specific area?
______________________________________________________________________________
Health Information:
Do you have or are you any of the following (Please circle Y=Yes
or N=No):
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Smoker?� Y /� N
Pregnant?� Y� /� N Contagious Disease? Y� /� N High/Low Blood Pressure?� Y� /� N Other Heart Conditions?� Y� /� N Allergies?� Y� /� N Epilepsy?� Y� /� N Seizures?� Y� /� N |
Diabetic?� Y� /� N
Vericose Veins?� Y� /� N Cancer?� Y� /� N Frequent Headaches?� Y� /� N Nausea?� Y� /� N Dimensia?� Y� /� N Surgery in last 3 years?� Y� /� N |
Are you currently suffering from any pain related to traumatic experience�
(i.e.:� Car accidents, sports injuries, surgeries)�� Y /
N
If yes, briefly explain (what and when):______________________________________________
Are you currently taking any medications or supplements (prescription
and non-prescript.) Y� /� N
If yes, name(s) of medication(s) and how often taken: ___________________________________
Do you have any conditions that may require a doctor�s note?� Y� /� N
Is it okay for me to contact your healthcare provider? Y� /�
N� If yes, please input info below.
Name:__________________
Phone #: (������ )____-_____
I attest that the above is true and accurate to the best of my knowledge
Signature��������������������������������������������������������� Date:
Disclaimer: By signing above, I agree that:
�I understand a massage therapist is not a doctor
and cannot prescribe medications or diagnose medical conditions.
Therapist does not discriminate on the basis of race,
religion, sexual preference or gender.
Therapist reserves the right to end session in the case
of sexual innuendo or advances from client, and client has same right in
instance of sexual advances or innuendo from therapist.
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