Client Intake Form

First Name
Last Name
Address
City
State
Zip	format xxxxx or xxxx-xxxx
Contact Phone	Format:xxx-xxx-xxxx
Email Address
Height	Inches
Weight	Lbs
Date Of Birth	Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920
Profession
Referred by
Physician Name
Physician Phone

Current Health
Do you exercise regularly and/or participate in any sports?	No Yes
If yes, which sports?
Have you recently suffered an injury?	No Yes
If yes, describe:
Have you had any areas of inflammation?	No Yes
If yes, describe:
Are you currently under the care of a physician?	No Yes
If yes, explain:
Have you had recent surgery?	No Yes
If yes, explain:
Medications Allergies:
Massage Experience
Have you had a professional massage before?	No Yes
What types of massage/bodywork have you had:
How long have you been receiving massage therapy?
Frequency of treatments?
What are your goals for treatment?:

Health History
Contact lenses?	No Yes
If yes, explain:
High blood pressure?	No Yes
If yes, explain:
Low blood pressure?	No Yes
If yes, explain:
Dentures?	No Yes
If yes, explain:
Back pain/Sciatica?	No Yes
If yes, explain:
Ulcer?	No Yes
If yes, explain:
Spinal problems?	No Yes
If yes, explain:
Tendonitis, bursitis, etc?	No Yes
If yes, explain:
Osteoporosis?	No Yes
If yes, explain:
Arthritis or joint disease?	No Yes
If yes, explain:
Broken bones?	No Yes
If yes, explain:
Diabetes?	No Yes
If yes, explain:
Easy bruising?	No Yes
If yes, explain:
Seizures/Convulsions?	No Yes
If yes, explain:
Skin problems?	No Yes
If yes, explain:
Multiple Sclerosis?	No Yes
If yes, explain:
Allergies?	No Yes
If yes, explain:
Nerve degeneration?	No Yes
If yes, explain:
Varicose veins?	No Yes
If yes, explain:
Cancer or tumors?	No Yes
If yes, explain:
Phlebitis/Blood clots?	No Yes
If yes, explain:
Infectious diseases?	No Yes
If yes, explain:
Heart problems?	No Yes
If yes, explain:
Any other medical condition(s) the therapist should be aware of?	No Yes
If yes, explain:

Please indicate any painful areas on your body?
If you're having a hard time explaining any painful areas, you can use this link to print Body Chart and bring it with you View Body Chart