Client Intake Form Name * First Name Last Name Email * Land Line (###) ### #### Mobile (###) ### #### Date of Birth * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact Name First Name Last Name Emergency Contact Phone (###) ### #### Occupation Relationship Medical History Medication * Are you taking medication Yes No Medication Details Allergies * Are you allergic to; oils, lotions, nuts, fruits skin etc? Yes No Allergy Details Are you Pregnant? * Yes No How many months Pregnant 1 Month 2 Months 3 Months 4 Months 5 Months 6 Months 7 Months 8 Months 9 Months Medical Interventions * Are you currently under medical supervision or receiving other medical interventions? Yes No Medical Supervision Please describe medical supervision or interventions Pre-existing Medical History Please select the conditions you have below Areas of swelling Autoimmune disorder Back / Neck Problems Bleeding disorders Blood clots Bruise easily Bursitis Cancer Contagious Condition Decreased sensation Diabetes Fibromyalga Headaches Heart condition Hypertension Kidney disease Multile scierosis Neurological condition Neuropathy Osteoarthritis Osteoporosis Phlebitis Sciatica Seizures Stroke Tendinitis TMJ Disorder Varicose veins Vertigo / Dizziness Areas of Broken Skin * Yes No Location of broken skin Have you had joint replacement surgery * Yes No Affected Joints Other Injury or health condition Massage Information Have you had a professional massage before * Yes No Reason for massage * Relaxation Specific problem Massage specific problem area Massage Pressure * Light Medium Firm Signature * By initialing below, I acknowledge that I am aware of the benefits and risks of massage therapy and that I have completed this form to the best of my knowledge. I also agree to inform my massage therapist of any health or medical changes. Thank You!You medical intake form has been submitted successfully.
