Client Intake Form
Name: First___________________ M.I.______ Last__________________ DOB____/____/____
Address:______________________________ City_________________State_____ Zip________
Home Phone(____) ____________ Work Phone (____) ____________ Cell (____) __________
E-mail_________________________________ Occupation______________________________
Pregnant [ ] yes [ ] no Occupational Stress [ ] yes [ ] no Emotional Stress [ ] yes [ ] no
Are you currently seeing a physician [ ] yes [ ] no if yes, explain__________________________
Exercise Activities_______________________________________________________________
Relaxation Activities_____________________________________________________________
Have you ever received a professional massage [ ] yes [ ] no Date of last massage ___/___/___
List any surgeries or injuries that you have or had______________________________________
______________________________________________________________________________
Major complaint_________________________________________________________________
List any medications that you are currently taking______________________________________
______________________________________________________________________________
Referred By: ___________________________________________________________________
Health History Mark an x for any current conditions. Mark p for any past conditions
Musculo-Skeletal Problems Circulatory Problems Nervous System Problems
[ ] Low Back Pain [ ] High Blood Pressure [ ] Fatigue
[ ] Mid Back Pain [ ] Low Blood Pressure [ ] Insomnia
[ ] Tight shoulder [ ] Varicose Veins [ ] Seizures
[ ] Neck Pain [ ] Blood Clots [ ] Herniated Disc
[ ] Feet Pain [ ] Poor circulation [ ] Trigeminal Neuralgia
[ ] Sciatic Pain [ ] Numb Hands and Feet [ ] Multiple Sclerosis
[ ] Headaches [ ] Stroke/ Heart condition Other
[ ] TMJ Dysfunction Respiratory [ ] Cancer / Tumors
[ ] Tendonitis [ ] Asthma [ ] Diabetes
[ ] Arthritis [ ] Allergies [ ] Eating Disorders
[ ] Bursitis [ ] Sinusitis [ ] Depression
[ ] Fibromyalgia/ Lupus [ ] Dizziness [ ] Constipation/Diarrhea
Infectious Diseases
[ ] HIV/ AIDS [ ] Hepatitis [ ] Other ________________
It is my choice to receive massage therapy. I realize that the treatment is being given for the well- being of my body and mind. This
includes stress reduction, relief from muscular tension, spasm, pain, and/or increased circulation. I agree to communicate with my
practitioner any time I feel like my well-being is being compromised or if my health condition changes. I will tell my therapist if there
are any changes in the medications that I am taking or if my overall health condition. I understand that massage practitioners do not
diagnose Illness, disease, or any physical or mental disorders, or prescribe medical treatment, pharmaceuticals, or perform spinal
thrust manipulations. I acknowledge that massage is not a substitute for medical treatment and it is recommended that I see a health
care provider for those services.
The information that I have provided is true to the best of my knowledge. I also understand that there is a cancellation period of 12
hours and will be charged if I fail to cancel within that time.
___________________________
(Print Name)
___________________________ _____/_____/_____
(Sign Name) (Date)