New Client Intake Form

***Please be sure to SCHEDULE ONLINE to confirm your appointment before completing the New Client Intake Form below.

Last Name:*

First Name:*

Address:

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code

E-mail:*

Phone Number:

Date of Birth:

List any current medications:

Referred by:

Emergency Contact:

What are your goals/expected outcomes for receiving massage/bodywork?

Have you ever received professional massage/bodywork before?

If yes, how recently?

List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):

Have you had any injuries or surgeries in the past that may influence today’s treatment?

Do these symptoms interfere with your activities of daily living (e.g., sleep, exercise, work, childcare)? If yes, please explain:

Health History

List any of the following health conditions that you currently have (If you are unsure, please ask): Please answer honestly, as massage may not be indicated for the above conditions.

Muscle or joint pain:

Muscle or joint stiffness:

Numbness or tingling:

Swelling:

Bruise easily :

Sensitive to touch/pressure:

High/Low blood pressure:

Stroke, heart attack:

Varicose veins:

Allergies, Shortness of breath, asthma:

Cancer:

Neurological (e.g. MS, Parkinson’s, chronic pain) Epilepsy, seizures:

Headaches, Migraines, Dizziness, ringing in the ears:

Digestive conditions (e.g. Crohn’s, IBS):

Gas, bloating, constipation:

Kidney disease, infection:

Arthritis (rheumatoid, osteoarthritis) Osteoporosis, degenerative spine/disk:

Scoliosis:

Broken bones:

Endocrine/thyroid conditions:

Depression, anxiety :

Consent for Treatment

If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage/bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. Understanding all of this, I give my consent to receive care.

Cancellation Notice

24hr cancellation notice is required. Late cancellations will be charged full price of the appointment

Client Signature:*

Parent or Guardian Signature (in case of a minor):

Date:*

***24hr cancellation notice is required. Late cancellations will be charged full price of the appointment***

24hr cancellation notice is required. Late cancellations will be charged full price of the appointment