Client Intake form Name * First Name Last Name Phone (###) ### #### Email * Reason for booking * Emergency Contact Name and Phone number * Are you under a physician’s regular care for this? YES NO What is your Occupation? * Do you allow photos or videos to be used for marketing or social media purposes? * Yes No Do you agree that this content can be used without further approval or compensation? * Yes No Do you understand that providing this content is completely voluntary and will not affect your treatment? * Yes No How did you hear about me? * Cardiovascular Do you have the following? Select all that apply first. Drop downs are follow up questions for what is selected. Please TYPE NA or SELECT NO if it does not apply. Low Blood Pressure High Blood Pressure Arrhythmia/ Congestive heart failure/ Valve disease Heart attack history Pacemaker or defibrillator Clotting disorders / DVT Musculoskeletal Do you have the following? Select all that apply first. Drop downs are follow up questions for what is selected. Please TYPE NA or SELECT NO if it does not apply. Arthritis Osteoporosis Recent Fractures / Sprains / Injuries Chronic Pain Fibromyalgia Neurological Do you have the following? Select all that apply first. Drop downs are follow up questions for what is selected. Please TYPE NA or SELECT NO if it does not apply. Headaches / Migraines Numbness / Tingling Multiple Sclerosis Parkinson’s Disease Seizures / Epilepsy Skin Do you have the following? Select all that apply first. Drop downs are follow up questions for what is selected. Please TYPE NA or SELECT NO if it does not apply. Rashes / Skin Conditions Open Wounds / Infections Bruising / Easy Bruising Allergic Reactions / Sensitivities Acne / Cystic Acne Scars / Scar Tissue Fungal Infections (Ringworm, Athlete’s Foot, Jock Itch, Nail Fungus) Bacterial Infections (Impetigo, Cellulitis, Folliculitis, Staph/MRSA) Viral Infections (Cold Sores/Herpes Simplex, Shingles/Herpes Zoster, Warts, Molluscum Contagiosum) Athletes/ Gym-goers & Active lifestyle Client Please TYPE NA or SELECT NO if it does not apply. Bodybuilder Powerlifter Crossfitters Highly Active Client Anything else you would like me to know? I consent to massage therapy provided by the therapist. I understand that pressure and techniques will be adapted to my comfort level and health needs. All personal and medical information provided will remain confidential, except as required by law. * I UNDERSTAND I understand that massage therapy is a wellness service and is not a substitute for medical diagnosis or treatment. The therapist does not diagnose or prescribe for medical conditions. I will inform the therapist of any pain, discomfort, or unusual reaction during the session. I understand that certain conditions may require clearance from a physician before receiving massage. * I UNDERSTAND I certify that the information I have provided on this intake form is accurate and complete to the best of my knowledge. I understand that it is my responsibility to update the therapist if any of my medical conditions or medications change. I understand that I certify that the information I have provided on this intake form is accurate and complete to the best of my knowledge. I understand that it is my responsibility to update the therapist if any of my medical conditions or medications change. * I CERTIFY Please type your LAST NAME & LAST 4 of your PHONE NUMBER to Sign. Click Submit to complete. Thank you!Reminder: You’ll receive a text or email 48 hours before your appointment. Please plan to arrive 10 minutes early to ensure a smooth check-in and a relaxed start to your session.See you soon!
