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Massage and Reflexology Intake Form

Client Information Form- CONFIDENTIAL

WELCOME!  We would like to make your appointment as pleasant and comfortable as possible.  If at any time you have any questions regarding your session, please let us know.

All information is confidential. It will not be shared with or sold to any other companies or parties.

The following sometimes occurs during massage and are normal responses to relaxation.  Trust your body to express what it needs to:  Need to move or change position, sighing, yawning, change in breathing, stomach gurgling, emotional feelings, energy shifts, falling asleep, memories

Please read the following information and sign below:

  1. I understand that although massage therapy can be very therapeutic, relaxing and reduce muscular tension, it is not a substitute for medical examination, diagnosis, and treatment.
  2. This is a therapeutic massage and any sexual remarks or advances will terminate the session and I will be liable for payment of the scheduled treatment.
  3. Being that massage should not be done under certain medical conditions, I affirm that I have answered all questions pertaining to medical conditions truthfully.

Today's Date: June 24, 2019

First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
First Client's Information

Massage & Body Treatment Intake

Have you had a professional massage before?*
No
Yes
Primary purpose of today's visit?*
Have you ever been hospitalized?*
No
Yes

Please list any significant injuries and when they occurred.

Please list any current medications:
Please check any symptoms/conditions that are current or have happened in the past:
Phlebitis
Chest pain
Headaches
Dizziness
Anxiety/Fatigue
Sinusitis
Head cold
Bronchitis
Eye strain
Varicose Veins
Abdominal pain
Pregnancy
Depression
Cancer
Digestion Issues
Emphysema
Diabetes
HIV/AIDS
Polio
Hernia
Hepatitis
Hypoglycemia
Arthritis
Blood Clots
Broken/Dislocated Bones
Bruise Easily
Stroke
Chronic Pain
Scoliosis
Skin Conditions
Seizures
Diverticulitis
Asthma
Heart Disease
Constipation/Diarrhea
High/Low Blood Pressure
Degenerative Disc Disease
Menstrual Problems
Other

Please explain:
Do you have any of the following today?
Skin Rash
Cold/Flu
Open Cuts
Severe Pain
Anything Contagious
Injuries/Bruises
Do you have allergies to?
Food (nuts, etc.)
Reaction to Skin Care Products
Environmental Allergens (dust, pollen, fragrances)

If any of the above are checked, please give details:
Are you wearing:
Contact lenses
Hearing Aid
Hairpiece

Where are you feeling discomfort?

What are your goals/expectations for this therapy session?
How much conversation do you prefer?*
Are you currently pregnant?*
Are you currently undergoing chemotherapy or radiation therapy?*
First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Second Client's Information

Massage & Body Treatment Intake

Have you had a professional massage before?*
No
Yes
Primary purpose of today's visit?*
Have you ever been hospitalized?*
No
Yes

Please list any significant injuries and when they occurred.

Please list any current medications:
Please check any symptoms/conditions that are current or have happened in the past:
Phlebitis
Chest pain
Headaches
Dizziness
Anxiety/Fatigue
Sinusitis
Head cold
Bronchitis
Eye strain
Varicose Veins
Abdominal pain
Pregnancy
Depression
Cancer
Digestion Issues
Emphysema
Diabetes
HIV/AIDS
Polio
Hernia
Hepatitis
Hypoglycemia
Arthritis
Blood Clots
Broken/Dislocated Bones
Bruise Easily
Stroke
Chronic Pain
Scoliosis
Skin Conditions
Seizures
Diverticulitis
Asthma
Heart Disease
Constipation/Diarrhea
High/Low Blood Pressure
Degenerative Disc Disease
Menstrual Problems
Other

Please explain:
Do you have any of the following today?
Skin Rash
Cold/Flu
Open Cuts
Severe Pain
Anything Contagious
Injuries/Bruises
Do you have allergies to?
Food (nuts, etc.)
Reaction to Skin Care Products
Environmental Allergens (dust, pollen, fragrances)

If any of the above are checked, please give details:
Are you wearing:
Contact lenses
Hearing Aid
Hairpiece

Where are you feeling discomfort?

What are your goals/expectations for this therapy session?
How much conversation do you prefer?*
Are you currently pregnant?*
Are you currently undergoing chemotherapy or radiation therapy?*
Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Third Client's Information

Massage & Body Treatment Intake

Have you had a professional massage before?*
No
Yes
Primary purpose of today's visit?*
Have you ever been hospitalized?*
No
Yes

Please list any significant injuries and when they occurred.

Please list any current medications:
Please check any symptoms/conditions that are current or have happened in the past:
Phlebitis
Chest pain
Headaches
Dizziness
Anxiety/Fatigue
Sinusitis
Head cold
Bronchitis
Eye strain
Varicose Veins
Abdominal pain
Pregnancy
Depression
Cancer
Digestion Issues
Emphysema
Diabetes
HIV/AIDS
Polio
Hernia
Hepatitis
Hypoglycemia
Arthritis
Blood Clots
Broken/Dislocated Bones
Bruise Easily
Stroke
Chronic Pain
Scoliosis
Skin Conditions
Seizures
Diverticulitis
Asthma
Heart Disease
Constipation/Diarrhea
High/Low Blood Pressure
Degenerative Disc Disease
Menstrual Problems
Other

Please explain:
Do you have any of the following today?
Skin Rash
Cold/Flu
Open Cuts
Severe Pain
Anything Contagious
Injuries/Bruises
Do you have allergies to?
Food (nuts, etc.)
Reaction to Skin Care Products
Environmental Allergens (dust, pollen, fragrances)

If any of the above are checked, please give details:
Are you wearing:
Contact lenses
Hearing Aid
Hairpiece

Where are you feeling discomfort?

What are your goals/expectations for this therapy session?
How much conversation do you prefer?*
Are you currently pregnant?*
Are you currently undergoing chemotherapy or radiation therapy?*
Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Information

Massage & Body Treatment Intake

Have you had a professional massage before?*
No
Yes
Primary purpose of today's visit?*
Have you ever been hospitalized?*
No
Yes

Please list any significant injuries and when they occurred.

Please list any current medications:
Please check any symptoms/conditions that are current or have happened in the past:
Phlebitis
Chest pain
Headaches
Dizziness
Anxiety/Fatigue
Sinusitis
Head cold
Bronchitis
Eye strain
Varicose Veins
Abdominal pain
Pregnancy
Depression
Cancer
Digestion Issues
Emphysema
Diabetes
HIV/AIDS
Polio
Hernia
Hepatitis
Hypoglycemia
Arthritis
Blood Clots
Broken/Dislocated Bones
Bruise Easily
Stroke
Chronic Pain
Scoliosis
Skin Conditions
Seizures
Diverticulitis
Asthma
Heart Disease
Constipation/Diarrhea
High/Low Blood Pressure
Degenerative Disc Disease
Menstrual Problems
Other

Please explain:
Do you have any of the following today?
Skin Rash
Cold/Flu
Open Cuts
Severe Pain
Anything Contagious
Injuries/Bruises
Do you have allergies to?
Food (nuts, etc.)
Reaction to Skin Care Products
Environmental Allergens (dust, pollen, fragrances)

If any of the above are checked, please give details:
Are you wearing:
Contact lenses
Hearing Aid
Hairpiece

Where are you feeling discomfort?

What are your goals/expectations for this therapy session?
How much conversation do you prefer?*
Are you currently pregnant?*
Are you currently undergoing chemotherapy or radiation therapy?*
Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Information

Massage & Body Treatment Intake

Have you had a professional massage before?*
No
Yes
Primary purpose of today's visit?*
Have you ever been hospitalized?*
No
Yes

Please list any significant injuries and when they occurred.

Please list any current medications:
Please check any symptoms/conditions that are current or have happened in the past:
Phlebitis
Chest pain
Headaches
Dizziness
Anxiety/Fatigue
Sinusitis
Head cold
Bronchitis
Eye strain
Varicose Veins
Abdominal pain
Pregnancy
Depression
Cancer
Digestion Issues
Emphysema
Diabetes
HIV/AIDS
Polio
Hernia
Hepatitis
Hypoglycemia
Arthritis
Blood Clots
Broken/Dislocated Bones
Bruise Easily
Stroke
Chronic Pain
Scoliosis
Skin Conditions
Seizures
Diverticulitis
Asthma
Heart Disease
Constipation/Diarrhea
High/Low Blood Pressure
Degenerative Disc Disease
Menstrual Problems
Other

Please explain:
Do you have any of the following today?
Skin Rash
Cold/Flu
Open Cuts
Severe Pain
Anything Contagious
Injuries/Bruises
Do you have allergies to?
Food (nuts, etc.)
Reaction to Skin Care Products
Environmental Allergens (dust, pollen, fragrances)

If any of the above are checked, please give details:
Are you wearing:
Contact lenses
Hearing Aid
Hairpiece

Where are you feeling discomfort?

What are your goals/expectations for this therapy session?
How much conversation do you prefer?*
Are you currently pregnant?*
Are you currently undergoing chemotherapy or radiation therapy?*
Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Information

Massage & Body Treatment Intake

Have you had a professional massage before?*
No
Yes
Primary purpose of today's visit?*
Have you ever been hospitalized?*
No
Yes

Please list any significant injuries and when they occurred.

Please list any current medications:
Please check any symptoms/conditions that are current or have happened in the past:
Phlebitis
Chest pain
Headaches
Dizziness
Anxiety/Fatigue
Sinusitis
Head cold
Bronchitis
Eye strain
Varicose Veins
Abdominal pain
Pregnancy
Depression
Cancer
Digestion Issues
Emphysema
Diabetes
HIV/AIDS
Polio
Hernia
Hepatitis
Hypoglycemia
Arthritis
Blood Clots
Broken/Dislocated Bones
Bruise Easily
Stroke
Chronic Pain
Scoliosis
Skin Conditions
Seizures
Diverticulitis
Asthma
Heart Disease
Constipation/Diarrhea
High/Low Blood Pressure
Degenerative Disc Disease
Menstrual Problems
Other

Please explain:
Do you have any of the following today?
Skin Rash
Cold/Flu
Open Cuts
Severe Pain
Anything Contagious
Injuries/Bruises
Do you have allergies to?
Food (nuts, etc.)
Reaction to Skin Care Products
Environmental Allergens (dust, pollen, fragrances)

If any of the above are checked, please give details:
Are you wearing:
Contact lenses
Hearing Aid
Hairpiece

Where are you feeling discomfort?

What are your goals/expectations for this therapy session?
How much conversation do you prefer?*
Are you currently pregnant?*
Are you currently undergoing chemotherapy or radiation therapy?*
Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Information

Massage & Body Treatment Intake

Have you had a professional massage before?*
No
Yes
Primary purpose of today's visit?*
Have you ever been hospitalized?*
No
Yes

Please list any significant injuries and when they occurred.

Please list any current medications:
Please check any symptoms/conditions that are current or have happened in the past:
Phlebitis
Chest pain
Headaches
Dizziness
Anxiety/Fatigue
Sinusitis
Head cold
Bronchitis
Eye strain
Varicose Veins
Abdominal pain
Pregnancy
Depression
Cancer
Digestion Issues
Emphysema
Diabetes
HIV/AIDS
Polio
Hernia
Hepatitis
Hypoglycemia
Arthritis
Blood Clots
Broken/Dislocated Bones
Bruise Easily
Stroke
Chronic Pain
Scoliosis
Skin Conditions
Seizures
Diverticulitis
Asthma
Heart Disease
Constipation/Diarrhea
High/Low Blood Pressure
Degenerative Disc Disease
Menstrual Problems
Other

Please explain:
Do you have any of the following today?
Skin Rash
Cold/Flu
Open Cuts
Severe Pain
Anything Contagious
Injuries/Bruises
Do you have allergies to?
Food (nuts, etc.)
Reaction to Skin Care Products
Environmental Allergens (dust, pollen, fragrances)

If any of the above are checked, please give details:
Are you wearing:
Contact lenses
Hearing Aid
Hairpiece

Where are you feeling discomfort?

What are your goals/expectations for this therapy session?
How much conversation do you prefer?*
Are you currently pregnant?*
Are you currently undergoing chemotherapy or radiation therapy?*
Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Information

Massage & Body Treatment Intake

Have you had a professional massage before?*
No
Yes
Primary purpose of today's visit?*
Have you ever been hospitalized?*
No
Yes

Please list any significant injuries and when they occurred.

Please list any current medications:
Please check any symptoms/conditions that are current or have happened in the past:
Phlebitis
Chest pain
Headaches
Dizziness
Anxiety/Fatigue
Sinusitis
Head cold
Bronchitis
Eye strain
Varicose Veins
Abdominal pain
Pregnancy
Depression
Cancer
Digestion Issues
Emphysema
Diabetes
HIV/AIDS
Polio
Hernia
Hepatitis
Hypoglycemia
Arthritis
Blood Clots
Broken/Dislocated Bones
Bruise Easily
Stroke
Chronic Pain
Scoliosis
Skin Conditions
Seizures
Diverticulitis
Asthma
Heart Disease
Constipation/Diarrhea
High/Low Blood Pressure
Degenerative Disc Disease
Menstrual Problems
Other

Please explain:
Do you have any of the following today?
Skin Rash
Cold/Flu
Open Cuts
Severe Pain
Anything Contagious
Injuries/Bruises
Do you have allergies to?
Food (nuts, etc.)
Reaction to Skin Care Products
Environmental Allergens (dust, pollen, fragrances)

If any of the above are checked, please give details:
Are you wearing:
Contact lenses
Hearing Aid
Hairpiece

Where are you feeling discomfort?

What are your goals/expectations for this therapy session?
How much conversation do you prefer?*
Are you currently pregnant?*
Are you currently undergoing chemotherapy or radiation therapy?*
Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Information

Massage & Body Treatment Intake

Have you had a professional massage before?*
No
Yes
Primary purpose of today's visit?*
Have you ever been hospitalized?*
No
Yes

Please list any significant injuries and when they occurred.

Please list any current medications:
Please check any symptoms/conditions that are current or have happened in the past:
Phlebitis
Chest pain
Headaches
Dizziness
Anxiety/Fatigue
Sinusitis
Head cold
Bronchitis
Eye strain
Varicose Veins
Abdominal pain
Pregnancy
Depression
Cancer
Digestion Issues
Emphysema
Diabetes
HIV/AIDS
Polio
Hernia
Hepatitis
Hypoglycemia
Arthritis
Blood Clots
Broken/Dislocated Bones
Bruise Easily
Stroke
Chronic Pain
Scoliosis
Skin Conditions
Seizures
Diverticulitis
Asthma
Heart Disease
Constipation/Diarrhea
High/Low Blood Pressure
Degenerative Disc Disease
Menstrual Problems
Other

Please explain:
Do you have any of the following today?
Skin Rash
Cold/Flu
Open Cuts
Severe Pain
Anything Contagious
Injuries/Bruises
Do you have allergies to?
Food (nuts, etc.)
Reaction to Skin Care Products
Environmental Allergens (dust, pollen, fragrances)

If any of the above are checked, please give details:
Are you wearing:
Contact lenses
Hearing Aid
Hairpiece

Where are you feeling discomfort?

What are your goals/expectations for this therapy session?
How much conversation do you prefer?*
Are you currently pregnant?*
Are you currently undergoing chemotherapy or radiation therapy?*
Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Information

Massage & Body Treatment Intake

Have you had a professional massage before?*
No
Yes
Primary purpose of today's visit?*
Have you ever been hospitalized?*
No
Yes

Please list any significant injuries and when they occurred.

Please list any current medications:
Please check any symptoms/conditions that are current or have happened in the past:
Phlebitis
Chest pain
Headaches
Dizziness
Anxiety/Fatigue
Sinusitis
Head cold
Bronchitis
Eye strain
Varicose Veins
Abdominal pain
Pregnancy
Depression
Cancer
Digestion Issues
Emphysema
Diabetes
HIV/AIDS
Polio
Hernia
Hepatitis
Hypoglycemia
Arthritis
Blood Clots
Broken/Dislocated Bones
Bruise Easily
Stroke
Chronic Pain
Scoliosis
Skin Conditions
Seizures
Diverticulitis
Asthma
Heart Disease
Constipation/Diarrhea
High/Low Blood Pressure
Degenerative Disc Disease
Menstrual Problems
Other

Please explain:
Do you have any of the following today?
Skin Rash
Cold/Flu
Open Cuts
Severe Pain
Anything Contagious
Injuries/Bruises
Do you have allergies to?
Food (nuts, etc.)
Reaction to Skin Care Products
Environmental Allergens (dust, pollen, fragrances)

If any of the above are checked, please give details:
Are you wearing:
Contact lenses
Hearing Aid
Hairpiece

Where are you feeling discomfort?

What are your goals/expectations for this therapy session?
How much conversation do you prefer?*
Are you currently pregnant?*
Are you currently undergoing chemotherapy or radiation therapy?*
Parent or Guardian's Email Address

Email*

Confirm Email*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Massage & Body Treatment Intake

Have you had a professional massage before?*
No
Yes
Primary purpose of today's visit?*
Have you ever been hospitalized?*
No
Yes

Please list any significant injuries and when they occurred.

Please list any current medications:
Please check any symptoms/conditions that are current or have happened in the past:
Phlebitis
Chest pain
Headaches
Dizziness
Anxiety/Fatigue
Sinusitis
Head cold
Bronchitis
Eye strain
Varicose Veins
Abdominal pain
Pregnancy
Depression
Cancer
Digestion Issues
Emphysema
Diabetes
HIV/AIDS
Polio
Hernia
Hepatitis
Hypoglycemia
Arthritis
Blood Clots
Broken/Dislocated Bones
Bruise Easily
Stroke
Chronic Pain
Scoliosis
Skin Conditions
Seizures
Diverticulitis
Asthma
Heart Disease
Constipation/Diarrhea
High/Low Blood Pressure
Degenerative Disc Disease
Menstrual Problems
Other

Please explain:
Do you have any of the following today?
Skin Rash
Cold/Flu
Open Cuts
Severe Pain
Anything Contagious
Injuries/Bruises
Do you have allergies to?
Food (nuts, etc.)
Reaction to Skin Care Products
Environmental Allergens (dust, pollen, fragrances)

If any of the above are checked, please give details:
Are you wearing:
Contact lenses
Hearing Aid
Hairpiece

Where are you feeling discomfort?

What are your goals/expectations for this therapy session?
How much conversation do you prefer?*
Are you currently pregnant?*
Are you currently undergoing chemotherapy or radiation therapy?*
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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