Client Intake Form

Client Intake Form

Personal Information

First Name

Last Name

Date of Visit

Birthday

Month

Day

Year

Gender

Phone

Occupation

Referred by

Address

Country/Region

Address

City

Zip / Postal code

Physician name

Physician phone

Emergency contact

Emergency phone

Reason for Visit

How would you rate your general health?

Poor

Fair

Good

Excellent

Have you ever had a professional message?

Yes

If so, when was your last massage?

Month

Day

Year

Describe injuries, concerns, or issues to address + causes and date of occurrences

Describe any treatment you've received for these particular issues

Describe your treatment goals

Health History

Reproductive

Given birth

Gynecological problems

Pregnant

Skin

Bruise easily

Skin irritations

Skin infections

Skin conditions

Waiver

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 will not hold my therapist responsible for any pain or discomfort I experience during or after the session.

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 agree to inform the therapist of any changes in my health and medical condition and that there shall be no liability on the therapist's part should I forget to do so.

I understand that massage is entirely therapeutic and non-sexual in nature.

By signing this release, I waive and release my therapist from any liability, past, present, and future, relating to massage therapy and bodywork.

Signature

Date

Gail Lordi