New Client Intake Form Name * First Name Last Name Email * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Occupation: * If you are under the age of 17, you must have the written consent of a parent or guardian to receive massage work. Date of Birth * MM DD YYYY Gender * Male Female Referred By: Massage Session Information What are your goals for your massage work today? * Preferred type of pressure (circle whichever apply) : * Light Medium Deep List current exercise activities and frequency: * Are you training for a specific event? * Any recent surgeries? If so, please explain: Please check below all that apply: Allergies Back or neck issues Bone or joint injuries Contagious skin condition Bruise easily Recent surgeries Varicose veins Current fever Migraines Smoke Heart condition Alcohol consumption High blood pressure Personal or work-related stress Back pain Arthritis Diabetes Epilepsy or seizures Are you pregnant? Any other medical conditions your therapist should be aware of, please specify: Please note any areas of tenderness or pain you would like to address: By clicking ‘submit’ I understand that massage therapy is intended for stress reduction, relief from muscular tension, or for increasing circulation. If I experience any kind of discomfort or pain during my session, I will notify my service provider immediately. I understand that a massage therapist does not diagnose illness, disease, or any medical condition. It has been explained that massage therapy in no way replaces a medical examination and/or diagnosis and that it is recommended that I see a physician for any physical ailment that I may have. Since it is imperative that the massage therapist be alerted to any existing physical conditions, I have stated all of my known medical conditions and will notify my massage therapist on any health updates. Thank you!
