Clinical Intake for Massage

Required Field

Personal Info

First Name

Last Name

Date of Birth (MM/DD/YYYY)

Gender

Occupation

Contact Info

Mobile Phone

Home Phone

Work Phone

Address

City

Country

Province / State

Postal / Zip Code

Emergency Contact

Emergency Phone

Relationship

Disclosure

Source of Referral

Characters: 0/255

If by an existing client, may we say thank you to the individual for your referral? (Check box if yes) See our website for full details regarding referrals

Disclosure: list name(s) and relationship to whom you authorize release of information to:

Characters: 0/255

Medical Intake

Medical Information

Medical Conditions: list all current and previous diagnosis

Characters: 0/255

General Health

Characters: 0/255

Primary Complaint

Characters: 0/255

Current Treatments

Characters: 0/255

Past Treatments

Characters: 0/255

Medications: list all current (and recent) medications and supplements

Injuries: list all current and prior injuries

Surgeries: list all surgeries along with the year

Additional Information

Are you currently being treated or have a history of cancer? (Check box if yes; please comment with details below.)

Are you currently pregnant? (Check box if yes; include how far along/what week you are in your pregnancy; if you are at high-risk or your physician is monitoring you for any conditions related to pregnancy comment below.)

Have you had previous massage treatments? (Check box if yes)

Review & Agree

Consent for Session (Review Required)

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Covid-19 (Review Required)

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Signature