Client intake form Name First Last Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell PhoneDate of Birth MM slash DD slash YYYY Occupation Emergency Contact Emergency Contact PhoneHave you ever received a professional massage? Yes No What type of massages have you had? Date of last massage MM slash DD slash YYYY What results do you want from your massage session? Are you sensitive to touch/pressure in any area? Yes No In which areas are you sensitive? MedicalAre you currently being treated by a Doctor, Chiropractor or other healing practitioner? Yes No Please specify purpose List any current medications and purpose: Previous HistoryDo you frequently suffer from stress? Yes No Do you experience frequent headaches? Yes No Are you pregnant? Yes No Are you wearing contact lenses? Yes No Are you diabetic? Yes No Do you have high blood pressure? Yes No Are you epileptic? Yes No Do you have tension or soreness in specific areas? Yes No Please Specify Do you suffer from chronic back pain? Yes No Do you have cardiac or circulatory problems? Yes No Do you have any numbness, or stabbing pains anywhere? Yes No Have you had any surgeries? Yes No Please Explain Do you have any injuries/accidents/illnesses still affecting you? Yes No Please Explain Do you have any other medical condition I should be aware of? Yes No Please Explain Additional Client Comments or Remarks:I have completed this form to the best of my knowledge and will inform the massage therapist of any change in my physical health. I understand that a massage therapist can not diagnose illness, disease, or any other medical, physical, or emotional disorder, nor perform any spinal manipulations. I am responsible for consulting a qualified physician for any ailments that I have. If you have a specific medical condition or specific symptoms, massage may be contraindicated. A referral from your primary care physician may be required prior to services being rendered. It is also understood that any illicit or sexually suggestive remarks or advances made will result in immediate termination of the session, and payment will be made for the full scheduled time. I agree to keep the therapist up to date as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should i forget to do so.* I have read and agree to the terms of service CommentsThis field is for validation purposes and should be left unchanged. Δ
