Please click on the link directly below to open a Word Document or feel free to print out the form below.
http://body-guidance.massagetherapy.com/files/Client%20Intake%20Form%20-%20mine.docx
Client Intake Form – Stephanie Stanton, LMT, BSNH
Name _____________________________________
Birthdate___________________
Address ____________________________________________________
City_______________________ State _____________ Zip ____________
Home Phone __________________
Cell Phone _____________________
Work Phone _________________
Email ___________________________
Occupation __________________________________________________
Referred By __________________________________________________
Emergency Contact (name and phone) _____________________________
Physicians name and number ____________________________________
When was your last bodywork session? ____________________________
Do you exercise regularly? What activities? ____________________________________________________________________________________________________________________________________________
Do you perform repetitive movement in your job? Please describe ____________________________________________________________________________________________________________________________________________
Do you sit for long periods at a computer or a workstation? ______________________________________________________________________
Are you currently under stress? In what ways? ____________________________________________________________________________________________________________________________________________
Do you have tension, discomfort, or pain? Where? ____________________________________________________________________________________________________________________________________________
Have you recently been injured, had surgery, or areas of inflammation? __________________________________________________________________________________________________________________________________________________________________________________________________________________
Do you have any allergies to oils, lotions, or ointments? __________________________________________________________________________________________________________________________________________________________________________________________________________________
List any medications you are currently taking? __________________________________________________________________________________________________________________________________________________________________________________________________________________
List any known allergies __________________________________________________________________________________________________________________________________________________________________________________________________________________
Have you ever experienced a stroke or an injury to your head?
__________________________________________________________________________________________________________________________________________________________________________________________________________________
Have you ever had an aneurysm? If yes, please describe ____________________________________________________________________________________________________________________________________________
Please list any medical conditions you have or are experiencing ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Are there any past surgeries or other medical conditions still causing you discomfort? __________________________________________________________________________________________________________________________________________________________________________________________________________________
I, (print name)______________________ understand that the bodywork session I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that this session should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that my therapist is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so.
Signature ___________________________________
Date __________________
