Massage Therapy Client Intake Form
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Name
First
Last
Date of Birth
MM slash DD slash YYYY
Contact Number
Emergency Contact Number
Relationship with Emergency Contact
Are you presently taking any medication?
Yes
No
PLEASE EXPLAIN
Have you had a recent major surgical procedure or injury?
Yes
No
PLEASE EXPLAIN
Are you currently seeing a Chiropractor, Physical Therapist, or Physician for an ongoing issue?
Yes
No
PLEASE EXPLAIN
Please select your stress level:
Low
1
2
3
4
5
High
Are you allergic to any Lotions or Oils?
Yes
No
PLEASE EXPLAIN
Please document any/all areas you would like more focus on for your session:
Musculo-Skeletal
Headaches
Joint stiffness/swelling Spasms/cramps
Broken/Fractured bones Strains/Sprains
Back, hip pain
Shoulder, neck, arm, hand pain
Leg, foot pain Chest, ribs, abdominal pain
Problems walking
Jaw pain/TMJ
Tendonitis
concentrating
Bursitis
Arthritis
Osteoporosis
Scoliosis
Other:
Other (Musculo - Skeletal)
Digestive
Indigestion
Constipation
Intestinal
gas/bloating
Diarrhea
Irritable bowel syndrome
Crohn's Disease
Colitis
Other:
Other (Digestive)
Skin
Rashes
Allergies
Athlete's foot
Acne
Impetigo
Hemophilia
Other
Other (Skin)
Circulator/Respiratory
Dizziness
Shortness of breath
Fainting
Cold feet or hands
Cold sweats
Stroke
Heart condition
Allergies
Asthma
High blood pressure
Low blood pressure
Other:
Other (Circulator/Respiratory)
Nervous System
Numbness/tingling
Fatigue
Sleep disorders
Ulcers
Paralysis
Herpes/shingles
Cerebral Palsy
Epilepsy
Chronic Fatigue Syndrome
Multiple Sclerosis
Muscular Dystrophy
Parkinson's Disease
Other:
Other (Nervous System)
Reproductive System
Pregnancy
Other
Other (Reproductive System)
Other Conditions
Loss of Appetite
Depression
Difficulty
Hearing Impaired
Visually Impaired
Diabetes
Fibromyalgia
Post/Polio Syndrome
Cancer
Tuberculosis
Other:
Other (Other Condition)
Consent
I agree to the following
I understand that a massage Therapist does not diagnose disease, illness, or prescribe any treatment or drugs, nor do they provide spinal manipulation. I understand that draping will be used at all times. I understand that if I become uncomfortable for any reason that I may ask the Therapist to end the massage session, and they will end the session. I understand that the massage Therapist may end the session for any inappropriate behavior. I have stated all of the conditions that I am aware of, and this information is true and accurate. I will inform the health care provider of any changes in my status.
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