Client Intake Form

Personal Information
1. Contact Information: *
2. Date of Birth: *
3. Occupation:
4. Postures assumed most of the day:
5. Primary Stressors:
6. If other, please describe:
7. Primary Physician:
8. Emergency Contact: *
9. Emergency Contact Relationship:
10. Emergency Contact Phone: *
11. How did you hear about us? *
Medical Information
12. Are you taking any medications? *
13. If yes, please list name and use:
14. Are you currently pregnant? *
15. If yes, how far along:
16. Any high risk factors?
17. Do you suffer from chronic pain? *
18. If yes, please explain:
19. What makes it better?
20. What makes it worse?
21. Have you had any recent injuries? *
22. If yes, please list:
23. Have you had any surgeries? *
24. If yes, please list:
25. Please indicate any of the following that apply to you: *
26. Explain any conditions you have marked above:
27. Are there any other conditions that not listed above?
28. Have you had a professional massage before?
29. What pressure do you prefer: *
30. Do you have any allergies or sensitivities? *
31. If yes, please explain:
32. What are you goals for this treatment session?
By signing below, I agree that all the information above is true.