Client Intake Form
Please complete this form before your session.
Personal Information
First Name
Last Name
Date of Birth
Gender
Select...
Female
Male
Non-binary
Prefer not to say
Phone
Email
Occupation
Referred by
Address
City
State
Zip Code
Emergency Contact Name
Emergency Contact Phone
Reason for Visit
How would you rate your general health?
Good
Excellent
Fair
Poor
Have you ever had a professional massage?
No
Yes
If yes, when was your last time?
Describe injuries, concerns, or issues to address (causes + dates):
Health History
Please check all that apply:
Cardiovascular
Congestive heart failure
Heart attack
Stroke
High blood pressure
Varicose veins
Pacemaker
Heart disease
Musculoskeletal
Arthritis
Bursitis
Tendonitis
Osteoporosis
Artificial joint
Jaw pain (TMJ)
Head & Neck
Headaches
Migraines
Dizziness
Vision/Hearing loss
Miscellaneous
Anxiety
Diabetes
Stress
Depression
Fibromyalgia
Cancer
Skin Conditions
Pregnant
Waiver & Signature
Please read and sign:
I understand that massage therapy is provided for stress reduction, relaxation, relief from muscular tension, and improvement of circulation and energy flow.
If I experience pain or discomfort during the session, I will immediately inform my therapist so that pressure/strokes can be adjusted to my level of comfort.
I understand that today's services are not a substitute for medical care and that my therapist is not qualified to diagnose, prescribe, or treat physical/mental illness.
I affirm that I have notified my therapist of all known medical conditions and injuries.
I waive and release my therapist from any liability, past, present, and future, relating to massage therapy and bodywork.
Digital Signature (Type Full Name)
Date
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