Client Intake Form (Online) Client Intake Form - Therapeutic Massage Personal Information:Name(Required) Phone (Day)(Required)Phone (Eve)(Required)Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Email(Required) Date of Birth(Required) MM slash DD slash YYYY Occupation Emergency Contact(Required)Phone(Required)The following information will be used to help plan safe and effective massage sessions. Please answer the questions to the best of your knowledge.Date of Initial Visit MM slash DD slash YYYY Have you had a professional massage before? Yes No If yes, how often do you receive massage therapy?(Required) Do you have any difficulty lying on your front, back, or side? Yes No If yes, please explain(Required) Do you have any allergies to oils, lotions, or ointments? Yes No If yes, please explain(Required) Do you have sensitive skin? Yes No Are you wearing contact lenses? Dentures A Hearing Aid Do you sit for long hours at a workstation, computer, or driving? Yes No If yes, please describe(Required) Do you perform any repetitive movement in your work, sports, or hobby? Yes No If yes, please describe(Required) Do you experience stress in your work, family, or other aspect of your life? Yes No If yes, how do you think it has affected your health?(Required) Muscle tension Anxiety Insomnia Irritability Other Is there a particular area of the body where you are experiencing tension, stiffness, pain or other discomfort? Yes No If yes, please identify(Required) Do you have any particular goals in mind for this massage session? Yes No If yes, please explain(Required) Circle any specific areas you would like the massage therapist to concentrate on during the session: Medical History In order to plan a massage session that is safe and effective, I need some general information about your medical history. Are you currently under medical supervision? Yes No If yes, please explain(Required) Do you see a chiropractor? Yes No If yes, how often?(Required) Are you currently taking any medication? Yes No If yes, please list(Required) Please check any condition listed below that applies to you: Contagious skin condition Open sores or wounds Easy bruising Recent accident or injury Recent fracture Recent surgery Artificial joint Sprains/strains Current fever Swollen glands Allergies/sensitivity Heart condition High or low blood pressure ( Circulatory disorder Varicose veins Atherosclerosis Phlebitis Deep vein thrombosis/blood clots Joint disorder/rheumatoid arthritis/osteoarthritis/tendonitis Osteoporosis Epilepsy Headaches/migraines Cancer Diabetes Decreased sensation Back/neck problems Fibromyalgia TMJ Carpal tunnel syndrome Tennis elbow pregnancy If yes, how many months? Please explain any condition that you have marked above(Required)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?Draping will be used during the session – only the area being worked on will be uncovered. Clients under the age of 17 must be accompanied by a parent or legal guardian during the entire session. Informed written consent must be provided by parent or legal guardian for any client under the age of 17.I, print name 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.Signature of client(Required)Date(Required) MM slash DD slash YYYY CAPTCHAPhoneThis field is for validation purposes and should be left unchanged. Δ
