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Client Intake Form

Client Information:

Address

Emergency Contact

Do you have private health insurance?

Do you have private health insurance?

Your Private Health Fund Insurance

Membership No.

Medical Information

1. Are you taking any medications?
NO
2. Are you currently pregnant?
No

3. Do you suffer from chronic pain?

3. Do you suffer from chronic pain?
4. Have you had any orthopedic injuries?
Untitled checkboxes field
No

5. Please indicate any of the following that apply to you.

Untitled multi-select field

Massage Information

1. Have you had a professional massage before?

Yes

2. Would you like to receive a remedial massage?

2. Would you like to receive a remedial massage?

3. What pressure do you prefer?

3. What pressure do you prefer?

4. Do you have any allergies or sensitivities?

4. Do you have any allergies or sensitivities?

5. Are there any areas (face, head, abdomen, etc.)you do not want massaged?

5. Are there any areas (face, head, abdomen, etc.)you do not want massaged?

6. What are your goals for this treatment session?

7. Please select any symptoms that apply to you and indicate when applicable

7. Please select any symptoms that apply to you and indicate when applicable
By signing below, you agree to the following. I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time.

Client Signature

Signature

Date completed