Denise M. Hermans-Smith, L.M.P.
18516 101st Avenue NE Suite 2 • Bothell, WA 98011
206-355-9319
Client Intake Form
Name Date
Address
City State Zip
Home Phone ( ) Cell ( )
E-mail Address:
Date of Birth: ___________________________ Occupation
Coverage: (Please circle) Private Insurance L&I Personal Injury Cash
Insurance Company & Phone #
Insurance I.D. or Policy # Date of Injury
Treatment History
When did you receive your last professional massage?
What results do you want from your massage sessions?
Please focus on the following area(s) of my body:
List any areas you would NOT want massaged:
Please be aware of the following conditions:
Are you currently under the care of a health care practitioner?
If yes, please give name, location, and list reason(s) why:
List any medications you are currently taking, including dosage:
Please include year and treatment received for the following:
List any surgeries:
Pregnancies? How many? I am weeks pregnant.
List any injuries / accidents still affecting you:
Other medical conditions that the massage therapist should be aware: i.e. Stressors,
Pain, fatigue, allergies, etc.
(recent, past or chronic conditions apply)
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Health History
Please indicate any of the following conditions that apply to you. Circle applicable condition.
Write if it is the right or left side and/or when symptoms generally onset on the following line
when appropriate. Please explain if condition is present or past.
Conditions
Heart condition
High/Low Blood Pressure
Blood clots
Phlebitis / Varicose veins
Thrombosis / embolism
Pinched nerve / nerve condition
Sciatica
Numbness / tingling
Low back / hip / leg pain
Neck/ shoulder / arm pain
Jaw pain / TMJ
Arthritis / gout
Osteoporosis
Bone or joint disease
Breathing difficulty / asthma
Cancer / tumors
Diabetes
Epilepsy
Multiple Sclerosis
Migraines / headaches
Whiplash
Chronic fatigue / pain
Fibromyalgia
Anxiety / stress syndrome
Other
I have listed all my known medical conditions and physical limitations. I will inform the massage
therapist of any changes occurring between massage sessions. I understand that the massage
therapist cannot make any diagnoses or prescription, nor can they perform any thrusting joint or
spinal manipulations / adjustments. I am responsible for consulting a qualified primary care
provider for any physical ailment I may have. I am also responsible for obtaining any
prescriptions from a primary care provider required by my insurance company regarding
coverage of massage. I agree to pay any balance of monies for massage therapy not covered by
my insurance company at the completion of each treatment. I agree to provide a 24-hour notice
for appointment cancellations. If I do not, I understand that I will still be charged a cancellation
fee of $35.00 for the session dependant upon discretion of the massage therapist & encouraged
that if you are feeling ill appointment should be rescheduled to a later date. I understand that if I
am late to a session that time will be forfeited from my scheduled session.
Signed Date
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