Client Intake Form

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NAME ______________________________________________   DATE_________________
ADDRESS____________________________________________________________________
PHONE_____________________________   EMAIL__________________________________
DOB_____________   OCCUPATION______________________________________________
1.   Have you had a professional massage before?  Frequency? 
 
2.   Do you have any pain or difficulty lying on your front, back, or side? 
 
3.   Allergies to oils—lotions?  nuts? latex? essential oils? fragrances? other? 
 
 
4.  Are you wearing contact lenses, dentures, hearing aids? Do you have any prosthetics, pacemaker, port, hardware (rod, ball/socket, plate, etc.)
 
4.   Do you sit for long hours at a workstation, computer, or in a vehicle? 
 
5.   Do you perform repetitive movement in your work, sports, or hobby?

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6.  How is your stress level?  How do you feel stress in your work, family, or other aspect of your life affects you?  (circle all that apply):  __muscle tension   ___anxiety   ___insomnia  __  irritability ___other(specify):

7.  Is there a particular area of the body where you are experiencing tension, stiffness, pain or other discomfort?  You may indicate it on the following chart and/or in words.




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8.  Is there anything that makes the pain better? 
 
            worse?
 
9.  Are you under medical supervision of an MD?  A chiropractor? Physical Therapist?  Massage Therapist?  If so, who?
 
 
 
 
 
10.  List current medications, vitamins, minerals, herbal supplements, essential oils you’re taking and what they are treating: 
 
 
 
 
 
 
 
11.  How often do you use alcohol, recreational drugs, tobacco, sodas?   List kind and frequency.
 
 
 
 
12.  Have you ever lived in an abusive situation at home or work? Experienced or witnessed physical violence (child abuse, mugging, rape, etc.)?  Or emotional abuse?  
 
 
 
Note any current or past medical conditions and note with a C or P  (current or past

Integumentary:
_____Boils
_____Fungal infections
_____Skin cancer
_____Eczema
_____Psoriasis
_____Herpes
_____Rash
_____Other
 
 
Musculoskeletal:
_____Fibromyalgia
_____Rheumatoid arthritis 
_____Osteoarthritis    
_____Tendonitis
_____Bursitis
_____Osteopenia/Osteoporosis
_____Headaches
_____Scoliosis
_____Whiplash
_____Carpal Tunnel
_____Strains/sprains  
_____Plantar fasciitis 
_____Concussion       
_____Flat feet or high arch
_____Tennis/golf elbow
_____Artificial joint(s)
_____Rotator cuff injury
_____Rib fracture/injury
_____Fracture within past year
_____Other
 
 
Circulatory:
_____Anemia
_____Heart disease
_____Blood pressure high or low
_____Varicose veins
_____Clotting disorder
_____High cholesterol
_____Bruise easily
_____Swollen feet
_____Reynaud’s syndrome
 
 
Other:
_____Cancer
_____Diabetes
_____Hypoglycemia
_____HIV/AIDS
_____Thyroid
_____Pituitary
_____TMJ Dysfunction
_____Tinnitus
_____Pressure behind eyes
_____Jaw locks open
_____Jaw pops

Nervous:
_____Decreased sensation or tingling
_____Learning disability
_____Autism spectrum
_____Seizure disorder
_____Multiple Sclerosis
_____Migraine Headaches
_____Mood disorder (depression/bi-            polar)
_____Stroke


Digestive:
_____Cirrhosis
_____Ulcers
_____Diverticulitis
_____Hepatitis
_____GERD
_____Hernia
_____Irritable bowel syndrome
_____Crohn’s disease
_____Kidney stones
_____Gall stones 
_____Troublesome constipation/diarrhea
_____Other


Respiratory:
_____Asthma
_____Emphysema
_____Sinusitis
_____Tuberculosis
_____COPD  
_____Chronic ear infections
_____Respiratory infections 
_____Allergies


Reproductive:
_____Breast cancer
_____Lactation problems
_____Prostate cancer
_____Endometriosis
_____Ovarian cysts
_____PMS
_____Peri- or Menopausal
_____Pregnant?
     if C--how many months?
     if P—how many times?
_____How many births?


​Any other medical condition:
 

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List accidents--car, falls (on ice, down stairs, etc.), sports injuries, blows to head, childhood incidents (bike wrecks, sledding accidents, falling out of a tree, etc.) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
List all surgeries, including dental surgeries (continue on back, if needed)
 
 
 
 
 
 
 
 
                                                                                        
 
Please note any other information you feel your therapist needs to know or that will be helpful
in treating you.
 
 
 
 
 
 
 
 
 
 
In the unlikely event of an emergency, please list two emergency contacts with names and numbers.
 
 
 
 
Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly and completely, to the best of my knowledge. I agree to keep the therapist updated as to any changes in my medical profile, and I release the therapist of any liability if I fail to do so.  
 
 
 
 
____________________________________________________________________________
Signed                                                                                                              Date