Client Intake Form Client Intake Form First Name(Required)Last Name(Required)Preferred Phone(Required)Email(Required) Address(Required)City(Required)US States- Select State -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingWashington DCARMED FORCES AFRICA \ CANADA \ EUROPE \ MIDDLE EASTARMED FORCES AMERICA (EXCEPT CANADA)ARMED FORCES PACIFICZip(Required)Date of Birth (mm/dd/yy)(Required)Gender IdentityPronounsHeightApproximate WeightOccupationEmergency Contact Name(Required)Relationship(Required)Phone(Required)What types of healthcare are you receiving? (Physician, Chiropractor, Acupuncture, Homeopath, etc.)Do you currently have, or recently had, any of the following conditions: (This information is confidential and may be important to your therapy.) Diabetes Arthritis Cancer (history) Allergies Numbness or Tingling Headaches/Migraines Skin Conditions Autoimmune Disease High Blood Pressure Heart Condition Varicose Veins Please elaborate if you selected any of the above conditions:Please note any recent injuries, surgeries, major accidents, or serious illness/conditions:Please list any medications or supplements you are currently taking for any of the above conditions:Are you pregnant or trying to become pregnant?(Required)NoYes - Currently PregnantYes - TryingDue Date (If pregnant):Previous massage/bodywork experience:(Required)NeverOccasionallyOftenTherapist Gender Preference?(Required)No PreferenceFemale Preferred, but will accept a male therapistFemale OnlyMale Preferred, but will accept a female therapistMale Only Clients are asked to keep the clinic informed on any changes to the above information(Required) I understand that: Massage therapy (Which include styles of: Swedish, Sports, Deep Tissue or Deep Massage) involves neither diagnosis nor treatment of any condition and is not a substitute for medical care. Draping will be used at all times. This is a full-body massage unless otherwise requested. Neither breasts nor genitalia will be massaged. (Required) If I am uncomfortable for any reason I may request to end the session and it will end promptly. The licensee must immediately end the massage session if a client initiates any verbal or physical contact that is sexual in nature. If client is under the age of 17, written consent from client’s guardian or parent is required. I affirm that I am able to receive Massage Therapy and that any of the information I have provided above does not prohibit me from doing so. I am aware that if I have a medical diagnosis that prohibits me from receiving Massage I must provide physicians written consent prior to services. Please itemize any areas of your body that you wish to be completely avoided:You will be asked to sign your intake form in person during your massage interview.CAPTCHA
