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Client Intake Form

All information is held strictest confidence. At no given point is information disclosed or shared without client’s written consent. You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose.

Full Name:

Birthdate:

Email:

Address:

Phone Number:

Which phone type have you provided?

Emergency Contact Name:

Emergency Contact Number:

Occupation:

Allergies:

Medications:

Have you ever had a massage before?

A
B

What are your Treatment Goals?

History of Pathology

Client services and all chart information are confidential.

Written authorization is required from you to release any information.

List Areas of Discomfort or Pain:

Have you ever injured this area before?

Describe Onset of Discomfort or Pain:

Rate of Pain Today: 1 = Very Little / 10 = Very Painful

At what time of day is the pain at its worse? *

A
B
C
D
E

Frequency - please select the most accurate

A
B
C
D
E

Have you ever been in an accident (automobile, work, falls, etc.) ?*

List all related treatments received for this injury.

Have you ever received therapeutic massage for a specific problem or injury?

A
B

Was the treatment used effective?

Is there anything that you do that creates, increases or decreases pain? *

What are the physical duties required of your occupation?*

What activities/hobbies do you enjoy?

Please list exercise and stress reduction activities (including frequency).

In what position do you most often wake up?

A
B
C
D

Are you currently seeing any other healthcare professional?

Please check any symptoms that apply to you:

(and indicate right or left when applicable)

Head

Neck

Shoulders

Arms & Hands

Mid-Back

Low Back

Hip

Legs and Feet

Type any questions or concerns you may have.

Massage Policies:

       • Please turn off your cell phone for optimal relaxation

       • Please reschedule your session if you are more than 15 minutes late

       • You will have a consultation with your therapist to discuss your session

       • You will be draped and at no time will genitalia or breast tissue be exposed

       • 24 hour cancellation notice is required to avoid being charged for your session

       • Your scheduled session is set aside for you. We do not double book appointments

       • Inappropriate behavior will not be tolerated and may be prosecuted to the full extent

of the law

• Should the session require, after your therapist has left the room, you may disrobe to

your comfort level

Client Agreement:

• I have stated my pertinent medical conditions, and will update the massage therapist of
any changes in my health status.

• I understand that therapeutic massage therapists do not diagnose illness, disease, any

physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals, or

perform joint mobilization.

• I acknowledge that massage therapy is not a substitute for medical examination or

diagnosis, and it is recommended that a physician be seen for that service.

• It is my choice to receive therapeutic massage as a form of therapy.

• I understand that treatment given is designed to address the care and prevention of

myofascial pain and dysfunction.

• I understand that my therapeutic massage therapist or I may end the session at any time
for any reason.

• I also understand that at any time I feel pain or discomfort during the session, I will

immediately inform my therapeutic massage therapist, so they adjust. 

By my electronic signature below, I agree to the massage policy and client agreement above.

Date:

Signature