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Newest Client Intake Form

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					       Therapeutic Massage Client Intake Form
                   Health History           Page 1
(Please answer all areas; filling out this form completely will help ensure the best possible care.)

Name: __________________________________                             Date: ________________________


Birthday:       ______________ Age________ Home Phone #                                    ______________


Home Address:____________________________________________________________


City:                                                 State:_____ Zip__________________________


Cell Phone Number:                                                 _______________________________


Email Address: ____________________________________________________________


Occupation _______________________________________________________________


Employer_________________________________________________________________


Do you have any of the following today:
[ ] Cold or Flu        [ ] Are you pregnant? No massage 1st trimester Due:___________

[ ] Open cuts/sores              [ ] Skin rash-where:_____________________________________

Have you ever had/do you have any of the following:

[   ] Diabetes                   [   ] High / Low BP: _________________________________
[   ] AIDS/HIV                   [   ] Blood Clot/DVT*         [ ] Kidney Disease*            [ ] DVT History*
[   ] Constipation               [   ] Lupus/ Crohns / Lymes   [ ] Stroke/CVA / TIA*          [ ] Other
[   ] Fibromyalgia Syndrome      [   ] Liver Disease           [ ] Neuropathy/Numbness*
[   ] Chronic Fatigue Syndrome   [   ] Heart Attack/MI*        [ ] Seizures
[   ] Cancer/Tumor/Chemo**       [   ] Allergies:              [ ] Within 6 weeks of Surgery*



*MD Note Required                      ** MD note required if within 1 year of treatment
    Therapeutic Massage Client Intake Form
                Health History           Page 2
What is the major complaint or condition you are seeking help for? _____________________
__________________________________________________________________________
When did this begin? _________________________________________________________
What brought it on? __________________________________________________________
__________________________________________________________________________
What have you done to get relief? _______________________________________________
What positions/activities aggravate the condition? ___________________________________
___________________________________________________________________________


What does this condition prevent you from doing?                   ________________________________
___________________________________________________________________________
___________________________________________________________________________
                                           R                   L                         L            R
Is this condition:       [ ] worsening      [ ] improving          [ ] unchanged.
Have you seen a physician for this?            Yes / No
May we contact your physician?             Yes / No Initial here: _____________
Physician Name / Number: ____________________________________
Are you now under medical/therapeutic treatment?                   Yes / No


                           Please mark your conditions, areas of concern,pain

                     R       R L       L        L         LR         R    R         L



                                   R                L                               L          R
     Therapeutic Massage Client Intake Form
                 Health History           Page 3


Please list all medications and nutritional supplements you are taking:
___________________________________________________________________________
Please list all surgeries in your lifetime: ____________________________________________
___________________________________________________________________________
Do you see a Chiropractor? ______ Who? ________________________________________
List other therapies you currently receive: __________________________________________
___________________________________________________________________________
Please list any additional comments regarding your health and well-being:
___________________________________________________________________________
How did you hear about us? ____________________________________________________
Emergency Contact Name: _____________________________________________________
Phone Number:                                        Relationship:________________________________


I have completed this form to the best of my knowledge and will inform the massage therapist of any change in my physical
health. I understand that a massage therapist cannot diagnose illness, disease, or any other medical, physical, or emotional
disorder, nor perform any spinal manipulations. I am responsible for consulting a qualified physician for any physical ailments
that I have. I understand that massage therapy is a therapeutic health aide and is NON-sexual.


I understand that if the massage therapist starts a session late, she/he will make it up to me at the end of the session if
possible, or will reduce my fee accordingly. I understand that if I arrive late, my session will end at the originally scheduled
time so the client following me is not penalized. I agree to give 24 hour notice for a scheduled session that I cannot keep.
I am aware that I may be charged the full fee for any missed sessions or for sessions that I do not give 24 hour notice to
cancel or reschedule.
Signature:                                                                                        Date:

				
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posted:2/10/2012
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