Client Intake Form- Bodywork session Today’s Date____________ Name _____________________________ Phone #__________________ Occupation_________________ Mailing Address___________________________________________________________________________ Email __________________________________________________________ Date of Birth______________ Please send me: Email confirmations and reminders for appointments Yes No Email newsletter/special offers (no more than 2/month) Yes No Referred by_____________________________________ May I thank them for referring you? Yes No The following information will be used to help plan safe and effective massage sessions. It will be kept confi- dential. Please answer to the best of your knowledge. Have you had professional massage before? Yes No How recently? Do you have an allergies or skin sensitivities to oils or lotions? If so, please explain Are you wearing contact lenses Yes No a hearing aid Yes No Do you sit for long hours at a workstation, computer or driving? Do you have any particular goals for this massage session? If yes, please explain Yes No Yes No Yes No Are you currently taking any medications, prescription or over-the-counter? If yes, please list Please circle any condition below that applies to you: depression easy bruising headaches/migraines recent injury food allergy or sensitivity Yes No high or low blood pressure circulatory issues numbness pregnancy osteo or rheumatoid arthritis Anxiety DVT/blood clots artificial joint TMJ osteoporosis Please explain any condition you circled above: varicose veins heart condition diabetes recent surgery epilepsy/seizures Is there anything else about your health history that you think would be useful for your massage therapist to know?
Client Intake Form- Therapeutic Massage Today’s Date____________ Please circle any specific areas you would like the massage therapist to concentrate on during the session: Consent for Treatment 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 should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage 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 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. Understanding all of this, I give my consent to receive care. Client signature _____________________________________________ Date________________