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Client Intake Form

First name*

Last name*

Email*

Phone*

Birthday*

Month

Day

Year

Address*

Emergency Contact*

Number*

Relationship*

Yes, subscribe me to your newsletter.

How Did You Hear About Us?

Medical Information

Are you taking any medication? *

Yes

No

If yes, please list:

Are you currently pregnant? *

Yes

No

If yes, how far along?

Are there any risk factors?

Do you suffer from chronic pain? *

Yes

No

If yes, please explain in detail.

What makes it better?

What makes it worse?

Do you have any injuries?

Yes

No

If yes, please explain

Please indicate any of these conditions that apply to you:*

Cancer

Headaches/Migraines

Arthritis

Diabetes

Joint Replacement(s)

High/Low Blood Pressure

Neuropathy

Fibromyalgia

Stroke

Heart Attack

Kidney Dysfunction

Blood Clots

Numbness

Sprains or Strains

N/A

Other

Massage Information

Have you ever received a professional massage before?*

Yes

No

What type of massage are you seeking?

Relaxation

Therapeutic/Deep Tissue

Other______________________________________

What type of pressure do you prefer?

Light

Medium

Deep

Do you have any allergies or sensitivities?

Yes

No

Please select any areas of discomfort or tenderness:*

Head

Neck

Face

Shoulders

Arms

Hands

Upper Back

Lower Back

Buttocks/Hips

Upper leg

Knees

Lower leg

Ankle/Foot

Stomach

Chest

Are there any areas you don't want massaged? If yes, please list them.

Please explain any conditions or areas of discomfort you have marked above:

I have completed this form to the best of my ability, and I agree to inform my therapist if any of the above information changes.

Print Name*

Date*

Month

Day

Year

Signature*

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Indigenous Massage

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