Client Intake -

PATIENT DETAILS

Patient Name

First

Last

Date

Date of Birth

Sex

Cell Phone Number

Email

Mailing Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Patient Current or Previous Occupation

Reason For Appointment

EMERGENCY CONTACT INFORMATION

Emergency Contact's Name

First

Last

Contact Number

Relationship to Patient

HEALTH INFORMATION

Are you taking any medications?

Yes
No

If Yes, Please List

Any allergies? (oils, lotions, nuts, fruits, skin, etc.)

Yes
No

If Yes, Please List

Are you pregnant?

Yes
No

If Yes, How Many Months?

Due Date?

Are you you currently under medical supervision or receiving other medical interventions?

Yes
No

If Yes, Please Describe

Please check ANY that apply to you

Areas of broken skin?(e.g.rash,wounds)

Yes
No

If Yes, Where?

History of joint replacement surgery?

Yes
No

If Yes, Which joint(s)?

Recent injuries or medical procedures in the past 2 years?

Yes
No

Signature Due currently

If Yes, Please describe:

Please describe any other injuries or health conditions:

MASSAGE INFORMATION

Have you had professional massage before?

Yes
No

How Recently?

Reason For Seeking Massage?

Relaxation
Specific Problem

If Specific Problem, Please Describe:

How much pressure do you prefer?

Light
Medium
Firm

How Did You Hear About Us?

Internet/Search Engine
Referral
Social Media

If Referral, Please State Name!

By signing below, I acknowledge that I am aware of the benefits and risks of massage therapy and that I have completed this form to the best of my knowledge. I also agree to inform my massage therapist of any health or medical changes.

Client Signature

Date

Therapist Signature

Date