Client Name Address Phone Number Email Website Full Name Date of Birth Gender Select Your Gender Male Female Other Address Phone Number Email Emergency Contact Name Emergency Contact Phone Physician/Healthcare Provider Phone Number Referred By Have you received professional massage before? Yes No If yes, how often? Preferred type(s) of massage Preferred pressure Light Medium Firm Reason for today’s visit What are your goals for treatment? (Pain relief, stress reduction, injury recovery, etc.) Are your symptoms affecting daily activities (sleep, work, exercise, childcare)? Yes No If yes, explain List your current symptoms (pain, stiffness, numbness, swelling, headaches, etc.): Are you currently pregnant? Yes No If yes, how many weeks? Are you seeking insurance reimbursement? Yes No If yes, type Do you have a physician referral? Yes No Please check any condition that applies to you (current or past) High/Low Blood Pressure Heart Disease / Stroke Blood Clots Cancer Diabetes Arthritis Osteoporosis Scoliosis Chronic Pain Headaches / Migraines Neurological Conditions Epilepsy / Seizures Asthma / Breathing Issues Digestive Disorders Kidney Disease Depression / Anxiety Recent Injury or Surgery (within past year) Allergies (please specify): Please explain any checked conditions, including treatment received Please mark or describe areas needing attention: Neck Shoulders Upper Back Lower Back Hips Legs Arms Feet Head Abdomen Other Type of discomfort Tension Pain Inflammation Numbness Spasm Please acknowledge I understand the fee structure and payment policy. I understand the cancellation/no-show policy. I understand massage is non-sexual and professional at all times. I understand I may stop the session at any time. I will inform the therapist of any discomfort during treatment. Special accommodations or needs I affirm that I have provided accurate health information and will update the therapist of any changes. I understand that inappropriate behavior will result in immediate termination of the session and I will be responsible for payment. By signing below, I consent to receive massage therapy treatment. Submit Now MASSAGE CLINIC CLIENT INTAKE FORM
