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Client Intake Form
Client Intake Form
PERSONAL INFORMATION
Name
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Name
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Address
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Physician’s Name
Physician's Name
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REASON FOR VISIT
How would you rate your general health?
Poor
Fair
Good
Excellent
Have you ever had a professional massage?
Yes
No
If yes, when was the last time?
Describe injuries, concerns, or issues to address+ causes and dates of occurrences
Describe any treatment you’ve received for these particular issues
Describe your treatment goals
HEALTH HISTORY
Cardiovascular Health
*
Congestive heart failure
Embolism
Heart attack
Heart disease
Hemophilia
High blood pressure
Low blood pressure
Pacemaker
Phlebitis
Poor circulation
Stroke
Thrombosis
Varicose veins
Family history
Head & Neck
*
Dizziness
Ear problems
Headaches
Hearing loss
Jaw pain (TMJ)
Migraines
Vision loss
Vision problems
Musculoskeletal
*
Arthritis
Artificial joint
Bursitis
Osteoporosis
Surgical pin/wire
Tendonitis
Neurological
*
Epilepsy
Multiple sclerosis
Numbness/tingling
Sensory loss/change
Sciatica
Seizures
Respiratory
*
Asthma
Bronchitis
Chronic Cough
Emphysema
Shortness of Breath
Sinusitis
Smoker
Tuberculosis
Family History
Reproductive
*
Given Birth
Gynecological problems
Pregnant
Skin
*
Bruise easily
Skin conditions
Skin infections
Skin irritations
Miscellaneous
*
Anxiety
Cancer
Depression
Diabetes
Digestive conditions
Fibromyalgia
HIV/AIDS
Stress
Other
If other, please explain.
WAIVER OF LIABILITY
<p>I understand that massage therapy is provided for stress reduction, relaxation, relief from muscular tension, and improvement of circulation and energy flow.</p><ul><li>If I experience pain or discomfort during the session, I will immediately inform my therapist so that pressure/strokes can be adjusted to my level of comfort. I will not hold my therapist responsible for any pain or discomfort I experience during or after the session.</li><li>I understand that today's services are not a substitute for medical care and that my therapist is not qualified to diagnose, prescribe, or treat physical/mental illness.</li><li>I affirm that I have notified my therapist of all known medical conditions and injuries.</li><li>I agree to inform the therapist of any changes in my health and medical condition and that there shall be no liability on the therapist's part should I forget to do so.</li><li>I understand that massage is entirely therapeutic and non-sexual in nature.</li><li>By signing this release, I waive and release my therapist from any liability, past, present, and future, relating to massage therapy and bodywork.</li></ul>
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