Client Intake Form
Name_________________________________________________________________________
Date__________________________________________________________________________
Address_______________________________________________________________________
City________________________ State__________Zip_________________________________
Birth date______________________________________________________________________
Occupation ____________________________________________________________________
How did you hear about me ______________________________________________________
List Exercise/Frequency__________________________________________________________
Home Number ______________________ Cell Number________________________________
Emergency Contact/Number______________________________________________________
Please list:______________________________________________________________________
Do you smoke? ______Yes _______No
Have you had a recent surgical procedure, accident, serious illness, injury, or been diagnosed with any mental health
conditions? ____Yes ____ No
If Yes, Please Explain:____________________________________________________________
Are you currently seeing a Chiropractor, Physical Therapist, or Physician for an
ongoing issue? ____ Yes ____No
Please explain and indicate name________________________________________________
Please circle your stress level:
Low 1 2 3 4 5 High
Would you like to be added to my newsletter? Y / N
Do you currently have or have had any of the following conditions:
(this information is confidential and may be important in your therapy).
___Allergies ___Diabetes ___Headaches
___Heart Condition ___Severe Pain
___Cold/flu ___Arthritis
___Skin Conditions
___Varicose Veins ___Numbness or Tingling
___Thyroid
___Cancer
___Autoimmune Disease ___Stroke (history) ___High Blood Pressure
Please list any medications/supplements you are presently taking any for anything above or an other
condition? _______________________________________________________________________
Please indicate with an (X), if any, the areas in which you are feeling discomfort:
Consent for Therapy and Waiver of Liability (please initial below to acknowledge)
I understand that a Massage Therapist does not diagnose disease, illness, or prescribe any
treatment or drugs, nor do they provide spinal or neck manipulation. _____
I understand that draping will be used at all times. Neither breast/genitalia will be massaged. _____
I understand that if I become uncomfortable for any reason that I may ask the therapist to end the session, which
will promptly end, and that I am responsible for full payment of service. ______
I understand that the Massage Therapist may end the session for any behavior deemed
inappropriate, and that the client will be responsible for full payment of service. ______
I have stated all of the conditions that I am aware of, and this information is true and accurate. _____
I will inform the Massage Therapist of any changes in my status. I acknowledge that I am taking full
responsibility for this information, and I am liable for my current health, and for the information I choose/do not
choose to provide. _______
1. Client hereby assumes full responsibility for receipt of the massage therapy, and releases and discharges
2.
Therapist from any and all claims, liabilities, damages, actions, or causes of action arising from the therapy
received hereunder, including, without limitation, any damages arising from acts of active or passive negligence on the part of the Therapist, to the fullest extent allowed by law.
Client, in signing this consent for Therapy and Waiver of Liability (“Consent”), understands and agrees that
this Consent will apply to and govern the current and all future therapy sessions performed by Therapist.
________________________________________
_________________________________________
Client Signature
Massage Therapist-LMT#MT019337