Client Intake Form

First name

Last name

Date of Birth

Phone

Address

Preferred Method of Conact

Text

Call

Gender

Female

Male

Non-Binary

Prefer not to say

Referred by:

Have you ever received professioal massage/bodywork before?

Yes

How recently?

Massage Style Preference

Swedish

DeepTissue

Pregnancy

Reflexology

Trigger Point Therapy

Shiatsu

Sports

I don't know/Not sure

Other

What kind of pressure do you prefer?

Light

Medium

Firm

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

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

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

Yes

If yes, explain:

Occupation

How may your job negatively impact your muscles (e.g., at a desk all day, labor intensive lifting/moving heavy items, in a vehicle with sudden movements):

Physical History: recent or recurring injuries, surgery history, chronic illnesses that may affect posture:

Select 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 these conditions:

Blood clots

Infections

Congestive heart failuer

Contagious diseases

Pitted edema

MASSAGE CONSENT AGREEMENT

I agree to the terms & conditions

CONSENT FOR TREATMENT

I agree to the terms & conditions

Your Signature (draw signature on line below)

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Txt: 424-500-3151

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