CONFIDENTIAL CLIENT INTAKE FORM

 

Name__________________________________________________Date:______________________

 

Address______________________________________________Postal Code___________________

 

Home Phone:_____________________Work________________________Cell__________________

 

May we contact you via e-mail? Y or N e-mail address______________________________________

 

Occupation:_______________________DOB: DD/MM/YY)______________Ht:______Weight______

Have you had a massage before? Y or N For relaxation or other reasons?:_____________________

Current Medication :________________________________________________________________

Previous Major Illness, Operations:_____________________________________________________

Accidents (please give details):________________________________________________________

 

Other Medical Conditions (e.g. hemophilia, diabetes):______________________________________

Family History (major illness, operations):________________________________________________

 

Please Indicate all the conditions you have experience. Mark C for current or P for past.

 

Joint/Soft Tissue Discomfort:                      General Symptoms:                                      Infectious:
__Arms                                                    __Fainting                                                  __Hepatitis
__Upper Back                                           __Dizziness                                                 __Tuberculosis
__Mid Back                                               __Loss of Sleep                                           __Human Immunodeficiency Virus(HIV)
__Lower Back                                           __Fatigue                                                   __Herpes
__Degenerativ                                           __Nervousness                                            __Cold
__Feet                                                     __Sudden Weight Loss/Gain                          __Flu
__Hands                                                   __ Numbness                                               __Athlete's Foot
__Hips                                                      __Tingling                                                   __Warts
__Jaw                                                      __ Paralysis                                                  Other____________________
__Knees                                                   __Headaches (Tension)
__Legs                                                     __Migraines                                                  Digestive:
__Neck                                                     __Belching/Gas                                              __Poor Appetite
__Osteo Arthritis                                                                                                           __Constipation
__Rheumatoid Arthritis                                     Cardiovascular:                                          __Diarrhea
__Sciatica Limitation of Movement                      __High Blood Pressure                               __Nausea
__Shoulders                                                    __Low Blood Pressure                                __Ulcer
in which joints:__________                               __Coronary Heart Disease                           __Vomiting
Other _________________                               __Heart Attack
                                                                      __Phlebitis
Skin:                                                               __Stroke/CVA                                         Eye, Ear, Nose, Throat:
__Rashes                                                         __Pacemaker                                           __Allergies
__Itching                                                        __Heart Murmur                                        __Frequent Colds
__Dryness                                                        __Bruise Easily                                          __Glasses or Contacts
__Boils                                                            __Palpitations                                            __Hearing Aid
Other_________________                                __ Varicose Veins                                       __ Hearing Loss
                                                                     __Swelling of the Ankles                             __Sinus Infection
Reproductive:                                                  __Poor Circulation                                       __Swollen Glands
__Pregnant
due date_______________                              Respiratory:
__Painful Menstruation                                    __Chronic Cough
__Heavy Flow                                                 __Bronchitis
__Irregular Cycle                                             __Asthma
__Swollen Breasts                                          __Hay Fever
__Menopausal                                                __Difficulty Breathing
__Pre-menopausal                                          __Smoking
__Post-menopasual                                         __Emphysema
__Birth Control                                               __Pneumonia
type________________

Lifestyle Questions
Regular eating habits  Yes  No                                                           Energy Level:  High  Average  Low
Do you take vitamins  Yes  No                                                           Do you suffer from stress?  Yes  No
  Type:_________________________                                                 Type:___________________________________
  Frequency:____________________                                                   Do you use a computer?  Yes  No
Regular exercise  Yes  No                                                                 How many hours per day:____________________
  Type: ______________________________________
  Frequency:__________________________________

 

Please read carefully, and sign.
I attest that the information I have provided is true and complete to the best of my knowledge.
I understand the information I have provided on this form is confidential and will not be released without my consent.
I consent to therapeutic massage treatment by the above named massage therapist.
I also understand that I am responsible for any changes incurred in the course of my treatment.
I understand that 24 hours notice is required to reschedule all future appointments, or full charges will apply.

 

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