New Energy Massage Client Intake Form by jw8490k


									Last Name: __________________________First Name:__________________________

                  New Energy Massage Client Intake Form

Street Address: _____________________________________ Birth Date: _________________________

City___________________ State__________ Zip__________ Telephone: _________________________

Have you received Therapeutic Massage? Yes ______ No_____ If so, how often? ____________________

What is the reason for your visit? ___________________________________________________________

Are there any areas that you want me to concentrate on? ________________________________________

Are there any areas that you want me to avoid being treated? _____________________________________

Are you under the care of a physician or other health care practitioner? ________________________If yes

is indicated, for what? ___________________________________________________________________

List any medications you are now taking and what they are used for: ______________________________


Please check off any of the following conditions or symptoms, which apply to you now or in the past:

____serious injuries                        ____headaches                       ____back pain

____blood clots                             ____low blood pressure              ____use of tobacco

____allergies                               ____skin infections                 ____contacts

____high blood pressure                     ____heart attack                    ____diabetes

____contagious conditions                   ____allergy to perfumes or oils     ____recent surgery

____AIDS                                    ____arthritis                       ____stroke

____varicose veins                          ____other                           _____________________

This massage is for therapeutic purposes only and completely NON-SEXUAL. Your cooperation is

I understand the massage services are designed to be a health aid and in no way to take place of a doctor’s
care when it is indicated. Information exchanged during any massage is educational in nature and is
intended to help you become more familiar and conscious of health status and is to be used at your own

Name (signature) ___________________________________________ Date ________________________

Emergency Contact: ____________________________________ Phone ___________________________

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