HTML Preview Client Intake Form page number 1.
Name ______________________________________ Phone ( ) ____________________ DOB ______________________
Address ________________________________________________ City ________________ State ________ Zip __________
E-mail: ____________________________________________________________________________________________________
Referred by: ________________________________________________________Phone ( )__________________________
In case of emergency: ______________________________________________ Phone ( )__________________________
Occupation ________________________ K Male K Female Physician____________________________________________
Health Insurance Carrier ____________________________________________________________________________________
Please take a moment to carefully read the following information and sign where indicated. If you have a specific
medical condition or specific symptoms, massage/bodywork may be contraindicated. A referral from your primary
care provider may be required prior to service being provided.
I understand that the massage/bodywork 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 practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage or bodywork should not be construed as a substitute for medical examina-
tion, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage/bodywork
practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as
such. Because massage/ bodywork 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 practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I also understand that any illicit or sexually sugges-
tive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment.
Client Signature ________________________________________ Date ______________________________________
Practitioner Signature __________________________________ Date ______________________________________
J Yes J No Do you frequently suffer from stress?
J Yes J No Do you have diabetes?
J Yes J No Do you experience frequent headaches?
J Yes J No Are you pregnant?
J Yes J No Do you suffer from arthritis?
J Yes J No Are you wearing contact lenses?
J Yes J No Are you wearing dentures?
J Yes J No Do you have high blood pressure?
J Yes J No Are you taking high blood pressure medication?
J Yes J No Do you suffer from epilepsy or seizures?
J Yes J No Do you suffer from joint swelling?
J Yes J No Do you have varicose veins?
J Yes J No Do you have any contagious diseases?
J Yes J No Do you have osteoporosis?
J Yes J No Do you have any allergies?
J Yes J No Do you bruise easily?
J Yes J No Any broken bones in the past two years?
J Yes J No Any injuries in the past two years?
J Yes J No Do you have tension or soreness in a specific area?
Please specify ______________________________
__________________________________________
J Yes J No Do you have cardiac or circulatory problems?
J Yes J No Do you suffer from back pain?
J Yes J No Do you have numbness or stabbing pains?
J Yes J No Are you sensitive to touch or pressure in any area?
J Yes J No Have you ever had surgery? Explain below.
J Yes J No Other medical condition, or are you taking any
medications I should know about?
Comments ______________________________________________
________________________________________________________
Have you ever experienced a professional massage or bodywork session? J Yes J No How recently?_________________
What are your massage or bodywork goals?______________________________________________________________________
What kind of pressure do you prefer? J light J medium J firm
If you answer “yes” to any of the following questions, please explain as clearly as possible.
Consent to Treatment of Minor: By my signature below, I hereby authorize ______________________________________ to administer massage, bodywork, or
somatic therapy techniques to my child or dependent as they deem necessary.
Signature of Parent or Guardian ________________________________________________________________________ Date ____________________
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lient Intake Form