Massage Client Intake form Client Information Name * First Name Last Name Date of Birth * MM DD YYYY Phone * (###) ### #### Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Have you ever had professional massage? * Select Yes No Massage Treatment Goals How would you like massage help you? Emergency Contact Information This person will be contacted in case of an emergency. Emergency Contact Name * First Name Last Name Emergency Contact Phone Number * (###) ### #### Emergency Contact Relationship * Health Data Please answer all questions to the best of your abilities. HSA or FSA? * I accept both HSA and FSA Select Yes No Maybe Any Allergies? * Select Yes No Skin Sensitivities? * Please List Under Allergies Select Yes No List Allergies Any accidents or injuries relevant to the massage? * Past or Present Select Yes No List & date accidents or injuries Any Medical Conditions? * Select Yes No List Medical Conditions like Asthma, Diabetes, Heart problems, Kidney problems, epilepsy, scoliosis, communicable disease, etc.? Any Medications? * Medications can potentially impact massage treatments due to their combined effect on the body. Select No Yes Specify Medication List location of painful or problem areas. * Tell me where is your pain? Do you perform any repetitive movement in your work, sports or hobby? * Do you sit at a computer desk? Or Play golf? Select Yes No Describe Repetitive Movement? List any areas you do NOT want massaged. example, NO face, hands, feet. Prenatal, Labor, Postpartum Clients Only Select Applicable Pregnancy Stage Pregnant Postpartum Nursing Family Planning Due Date If applicable MM DD YYYY Number of Weeks Postpartum? If applicable Did You have a C-section? Select Yes No Have you EVER had an epidural? Even if it was 40 years ago, epidural scares can still cause back pain years later. Select Yes No Physician/Midwife's Phone Name Physician/Midwife's Phone (###) ### #### Are You Suffering From Engorgement or Mastitis? Select Yes No Interested in Doula Services? Select Yes No Maybe Client Agreement It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status. * copy available upon request Yes, I Agree. No, I Do Not Agree. I am responsible for all charges for all service provided. Unless otherwise negotiated in writing. * Yes, I Agree. No, I Do Not Agree. Type Full Name Date * MM DD YYYY Thank you, I look forward to serving you with a healing massage. I hope you look forward to a magical experience.
