Client Information & Intake Form
Full Name *
Best Contact Phone
Street Address
City, State, Zip
Email
Date of Birth (mm/dd/yyyy)
MM
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DD
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YYYY
Occupation
Emergency Contact Name
Emergency Contact Phone
Do you have any difficulty lying on your front, back, or side?
If yes, please explain:
Do you have any allergies to oils, lotions, or ointments?
If yes, please explain:
Are you wearing contact lenses?
Clear selection
Do you wear dentures?
Clear selection
Do you wear hearing aids?
Clear selection
Do you sit for long hours at a workstation, computer, or driving?
Clear selection
Do you perform any repetitive movement in your work, sports, or hobby?
If yes, please explain:
Do you have any particular goals in mind for this massage session?
Medical History
Are you currently under medical supervision for any specific condition?
Please explain:
Do you see a chiropractor?
If yes, how often?
Are you currently taking any medication?
If so, please list:
Please select any condition listed below that applies to you:
Draping will be used during the session. Only the area being worked on will be uncovered. Clients under the age of 17 must be accompanied by a parent or legal guardian during the entire session.
I _______________________ (type name below) understand that the massage 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 therapist 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, chiropractor or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said during 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 therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so.
Approval of Client
Date
MM
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DD
/
YYYY
Approval of Massage Therapist
Date
MM
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DD
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YYYY
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