Client Intake Form

 

Name
Phone
Alternate Phone
Email
Address
Date of Birth
Occupation
Employer
Referred by

 

Have you recently (past 3 years) had surgery? Yes No
Do you wear contact lenses or dentures? Yes No
Do you take any prescribed medications? Yes No
Do you have chronic back pain? Yes No
Do you have frequent headaches? Yes No
Do you have any heart problems? Yes No
Are you constantly fatigued? Yes No
Do you have high or low blood pressure? Yes No
Do you have varicose veins? Yes No
Are you pregnant? Yes No
Have you ever had cancer? Yes No
Do you have arthritis? Yes No
Do you have pain which radiates down arms or legs? Yes No
Have you suffered an acute (recent) injury? Yes No
Please rate your tension level from 1-10 (1 lowest - 10 highest)
Please explain any YES answers:

Do you have any other medical conditions of which we should be aware?		 Yes No
If YES please specify:

I have stated all conditions that I am aware of and this information is true and accurate.  I will inform the massage therapist of any changes in my health status before my next massage. The massage treatment given here is for the sole purpose of stress reduction, relief from muscle tension or spasm and to increase circulation and energy flow. The massage therapist does not diagnose or prescribe for medical illness, disease, or any other physical or mental disorder. The massage therapist does not do spinal manipulations. Massage therapy is nota substitue for medical examination or diagnosis, and it is recommended that a physician be seen for any ailment that you may have.

I agree to the above information

I do not agree to the above information