New Client Intake Form

To help understand you and your personal needs please provide some background information on yourself.

Name
Date of Birth
Sex Male Female
Height
Weight

When would you like to schedule?
Date
Time of Day

 

Please provide the following contact information:

Date of Birth
Address
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
E-mail
Emergency Contact
Phone
Occupation
Health Insurance Carrier
Physician

Please take a moment to carefully read the following information and sign where indicated.  if you have a specific medical condition or specific symptoms, massage/bodywork may be contraindicated.  A referral from your primary care provider may be required prior to service being provided.

Yes    No         Have you ever experienced a professional massage or bodywork session?  How Recently?

Yes    No          Do you frequently suffer from stress?
Yes    No           Do you have diabetes?
Yes    No           Do you experience frequent headaches?
Yes    No         Are you pregnant?
Yes    No            Do you suffer from arthritis?
Yes    No          Are you wearing contact lenses?
Yes    No            Are you wearing dentures?
Yes    No           Do you have high blood pressure?
Yes    No           If "yes" to previous question are you taking medication for this?
Yes    No            Do you suffer from epilepsy or seizures?
Yes    No          Dou you suffer from joint swelling?
Yes    No            Do you have varicose veins?
Yes    No         Do you have any contagious diseases?
Yes    No          Do you have osteoporosis?
Yes    No          Do you have allergies? Please explain
Yes    No     Do you bruise easily?
Yes    No        Have you broken any bones in the past two years?
Yes    No           Have you been in an accident or suffered any injuries in the past two years?
Please specify:        
Yes    No           Do you have cardiac or circulatory problems?
Yes    No           Do you suffer from back pain?
Yes    No           Do you have numbness or stabbing pains anywhere?
Yes    No          Have you ever had surgery?  Explain below?
Yes    No            Do you have any other medical condition or are you taking any medication I should know about?
Comments:       

I understand that the massage/bodywork I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage or bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that massage/body-work practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner's part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment.

  I agree with the above paragraph and confirm that all the information provided is accurate to the best of my knowledge.