Serenity Now Massage Therapy Client Intake Form printable pdf download

Serenity Now Massage Therapy Client Intake Form—PLEASE PRINT LEGIBLY

Name:________________________________Phone:______________

DOB: ___/___/___

Address:____________________________________________________________________

City:________________________________ST:__________ Zip: _______________________

Email: _______________________________

Emergency Contact: ___________________________________Phone:__________________

Where did you hear about us? Google

Website

Current Client Other:_______________

Occupation: _______________________________

Please take a moment to carefully read and provide the following information. If you have a specific medical

condition or specific symptoms, massage/bodywork may be contraindicated and a referral from your primary

care provider may be required prior to service being provided.

Y N Do you frequently suffer from stress?

Y N Do you have diabetes?

Y N Do you have a thyroid condition?

Y N Do you experience frequent headaches?

Y N Are you pregnant?

Y N Do you suffer from arthritis?

Y N Do you bruise easily?

Y N Any injuries in the past two years?

Y N Do you suffer from joint swelling?

Y N Have you ever had surgery? Year? __________

Y N Do you suffer from epilepsy or seizures?

Y N Do you have varicose veins?

Y N Do you have any contagious diseases?

Y N Do you have osteoporosis?

Y N Any broken bones in the past 2 years?

Y N Do you suffer from back pain or disk herniation?

Y N Do you have numbness or stabbing pains?

Y N Are you sensitive to touch or pressure in any areas?

Y N Do you have high blood pressure and/or take medications to manage blood pressure?

Y N Do you have cardiac or circulatory problems?

Y N Do you have any allergies or sensitivities? (i.e. nuts, iodine, shellfish, flowers, scents)

Y N Any other medical conditions or medications you are taking? __________________________________

Additional Medical information/comments:______________________________________________________

_________________________________________________________________________________________

Over

Serenity Now Massage Therapy—Intake Form Sept 2013.

Serenity Now Massage Therapy Client Intake Form