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Client Intake Form – Therapeutic Massage Personal Information

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					                               Client Intake Form – Therapeutic Massage

Personal Information:
Name ___________________________________ Date of Birth ____________________________
Phone (Day)______________________________ Phone (Eve) ____________________________
Email __________________________________________________________________________
Address ________________________________________________________________________
City/State/Zip ____________________________________________________________________
Emergency Contact Phone/Relationship _______________________________________________
Whom May We Thank for Referring You? ______________________________________________

            The following information will be used to help plan safe and effective massage sessions.
                          Please answer the questions to the best of your knowledge.

Massage Experience
1.   Yes     No Have you had a professional massage before?
       What types of massage/bodywork have you had? _________________________________________
       __________________________________________________________________________________
       How long have you been receiving massage therapy? _____________________________________
       Frequency of treatments? ___________________________________________________________
2.   Yes     No Do you have any allergies to oils, lotions, or ointments and/or sensitive skin?
      If yes, please explain ` ________________________________________________________________
3. What are your goals for treatment? _________________________________________________________

Lifestyle
4. How many hours do you sit at a computer/workstation or drive a car? ___________ hours per day/week
5.     Yes       No Do you perform any repetitive movement in your work, sports, or hobby?
         If yes, please describe _______________________________________________________________
6.     Yes       No Do you exercise regularly and/or participate in any sports?
         If yes, what frequency and types of exercise/sports? ________________________________________
7. How much water do you drink in an average day? ______________________________________________
8.     Yes       No Do you experience stress in your work, family, or other aspect of your life?
If yes, how do you think it has affected your health? ______________________________________________

Please circle on the diagram below where you are
experiencing pain and use one of the letters below to
describe the pain.
P – Sharp Pain
A – Aches
I – Inflammation
N – Numbness
S – Stiff
Current Health
9.    Yes       No Have you recently suffered an injury?
       If yes, describe: _____________________________________________________________________
10. Yes         No Are you currently under the care of a physician/chiropractor?
       If yes, explain: ______________________________________________________________________
       Physician Name/Phone _______________________________________________________________
       Chiropractor Name/Phone _____________________________________________________________
11. Yes         No Have you had recent surgery?
       If yes, explain: ______________________________________________________________________
13. Please list any Medications/Allergies you are currently taking/prescribed: __________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

14. Please check any condition listed below that applies to you:
   contagious skin condition            phlebitis                         open sores or wounds
   deep vein thrombosis/blood clots     easy bruising                     joint disorder/rheumatoid
   recent accident or injury            osteoporosis                      arthritis/osteoarthritis/tendonitis
   recent fracture                      epilepsy                          recent surgery
   headaches/migraines                  artificial joint                  cancer
   sprains/strains                      diabetes                          current fever
   decreased sensation                  swollen glands                    back/neck problems
   allergies/sensitivity                Fibromyalgia                      heart condition
   TMJ                                  high or low blood pressure        carpal tunnel syndrome
   circulatory disorder                 tennis elbow                      varicose veins
   atherosclerosis                      pregnancy If yes, how many months? _________________________
Please explain any condition that you have marked above _________________________________________
________________________________________________________________________________________

15. Is there anything else about your health history that you think would be useful for your massage practitioner
to know to plan a safe and effective massage session for you? ______________________________________
________________________________________________________________________________________


I, _________________________ understand that the massage I receive is provided for the basic purpose of
relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will
immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I
further understand that massage should not be construed as a substitute for medical examination, diagnosis,
or treatment and that I should see a physician, chiropractor or other qualified medical specialist for any
mental or physical ailment that I am aware of. I understand that massage therapists are not qualified to perform
spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing
said in the course of the session given should be construed as such. Because massage should not be
performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and
answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile
and understand that there shall be no liability on the therapist’s part should I fail to do so.

I understand it is the policy of Sanctuary|Massage to require 24 hours notice to cancel or reschedule any
appointment or a $25 no-show fee may be implemented. Late arrivals may result in a shortened session,
completing at the original end time. I also understand that any returned checks will accrue a $25 fee.



_________________________________________                   _________________________________________
Signature of client                  Date                   Signature of Massage Therapist       Date

				
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