Client Intake Form

Contact Information

Name___________________________________________________
Date______________________________

Address_____________________________________ City________________________ State_________ Zip______

Phone(home/work/cell)______________________________________________________________

E-mail____________________________________________
Birth Date_______/_______/__________

Emergency Contact__________________________________________
Relationship____________________________

Phone(home/work/cell)______________________________________________________________

How did you hear about us?________________________________________________________________

Current Health

Have you ever received massage therapy before? Y N
When/Results_______________________

How are you feeling today? ______________________________________________________________

Reason for today’s visit ________________________________________________________________

Please indicate areas of your body to pay special attention to______________________________

Please indicate any areas of your body you do not want touched____________________________

Please use the diagram below to indicate areas of tension or discomfort

Medical History

Occupation/Activities/Hobbies_________________________________________________________

Are you currently under the care of a physician? Y N

Name, phone number, and what for__________________________________________

Are you taking any medications or other substances (supplements, herbs, alcohol, or recreational drugs)?__________________________________________________________________________

Please list any surgeries, accidents, or major illnesses_______________________________________

Have you ever been diagnosed with cancer? Y N

Type and current condition______________________________________________________

Do you have any communicable diseases? Y N

Type and current condition____________________________________________________

Consent for Care

It is my choice to receive massage therapy. I am aware of the benefits and risks or massage and give my consent for massage. I understand that there is no implied or stated guarantee of success or effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examinations, or diagnosis. I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status.

Client Signature__________________________________________________
Date____________________