Client intake form Name First Last Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell PhoneDate of Birth Date Format: MM slash DD slash YYYY OccupationEmergency ContactEmergency Contact PhoneHave you ever received a professional massage? Yes No What type of massages have you had?Date of last massage Date Format: MM slash DD slash YYYY What results do you want from your massage session?Are you sensitive to touch/pressure in any area?YesNoIn which areas are you sensitive?MedicalAre you currently being treated by a Doctor, Chiropractor or other healing practitioner? Yes No Please specify purposeList any current medications and purpose:Previous HistoryDo you frequently suffer from stress?YesNoDo you experience frequent headaches?YesNoAre you pregnant?YesNoAre you wearing contact lenses?YesNoAre you diabetic?YesNoDo you have high blood pressure?YesNoAre you epileptic?YesNoDo you have tension or soreness in specific areas?YesNoPlease SpecifyDo you suffer from chronic back pain?YesNoDo you have cardiac or circulatory problems?YesNoDo you have any numbness, or stabbing pains anywhere?YesNoHave you had any surgeries?YesNoPlease ExplainDo you have any injuries/accidents/illnesses still affecting you?YesNoPlease ExplainDo you have any other medical condition I should be aware of?YesNoPlease ExplainAdditional 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 PhoneThis field is for validation purposes and should be left unchanged.
