For your convenience to save time, before you arrive for your appointment, please print this page, fill it out, and bring it with you. Or you may prefer to e-mail this form prior to your appointment. To do this: With your cursor somewhere on this page, right click on your mouse, then click on "select all". Then, with your cursor positioned on a highlighted area on the page, right click on your mouse again and click on "copy". Open your e-mail system, and open a new e-mail page. With your cursor on the blank body of the new e-mail page, right click your mouse and click on "paste". Type your information on the form and e-mail to amassageforfitness@verizon.net. You can sign it upon your arrival. Thank you!
CLIENT INTAKE FORM
NAME _____________________________________________________________________________________
STREET ADDRESS __________________________________________________________________________
PHONE (HOME) ___________________ (WORK) ______________________ (CELL) ____________________
E-MAIL ADDRESS ________________________________________ OCCUPATION ______________________
AGE (CIRCLE ONE): UNDER 18 (NEEDS PARENTAL CONSENT) 18-30 31-40 41-50 51-60 OVER 60
REFERRED BY ______________________________________________________________________________
IF NOT REFERRED, HOW DID YOU COME TO INQUIRE? (GOOGLE, YAHOO, CITYSEARCH, MERCHANTCIRCLE, YELLOW, YELLOWPAGES, SUPERPAGES, ANOTHER SEARCH ENGINE [WHICH ONE?], A PARTICULAR MASSAGE WEBSITE [WHICH ONE?], LIVING.WELL MAGAZINE AD, YELLOW PAGES DIRECTORY, ETC.) PLEASE GIVE DETAILS, SUCH AS THE KEYWORDS YOU USED FOR YOUR SEARCH, IF YOU REMEMBER.________________________________________________________________
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The following series of questions are to familiarize the therapist with important information about you, the client. It is of the utmost importance that you take the time to answer these questions to the best of your ability. This will help the therapist meet your needs with your massage. Please notify your therapist of any changes in your medical condition. All information is confidential.
Primary reason for appointment _________________________________________________________________
Have you had a professional massage before?
Do you have any allergies?
Do you have any skin conditions?
Do you have any infectious conditions?
Have you had any surgery?
Do you have any spinal issues?
Do you wear contact lenses or dentures?
Do you have frequent headaches?
Are you constantly tired?
Do you have any heart issues?
Do you have high blood pressure?
Do you have vericose veins?
Do you have any history of blood clots?
Do you have any cancer?
Do you have arthritis?
Is there any other medical condition the therapist should be aware of?
Please explain any "yes" answers to the above questions. ___________________________________________
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Do you participate in any sports or exercise program regularly? If "yes", what and how often? ______________
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Are you currently under a doctor's care? If "yes", please describe. ____________________________________
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Are you taking any medications? If "yes", please describe. __________________________________________
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Have you had any injuries in the past? If "yes", please describe. ______________________________________
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FEMALE CLIENTS ONLY: Are you pregnant? If "yes", how many months? ____________________________
Is your menstrual period due within the next week? ________________________________________________
I, ____________________, understand that the massage therapy given here is for the purpose of stress reduction, relief from muscular tension or spasm, or for increasing circulation, and is not of a sexual nature. I understand the massage therapist does not diagnose illness, disease, or any other physical or mental disorder. As such, the massage therapist prescribes neither medical treatment nor pharmaceuticals, nor performs any spinal manipulations. It has been made very clear to me that this massage therapy is not a substitute for medical examinations and/or diagnosis and that it is recommended that I see a physician for any physical conditions. I have stated all my known medical conditions and take it upon myself to keep the massage therapist updated on my physical health. If I am under 18 years of age, a parent or parental guardian must also sign for approval of my getting massaged. Signature of client ____________________________________________ Date _________________________
Signature of parent (if under 18) _________________________________ Date _________________________
A Massage For Fitness...Therapeutic massage fit for you! Your body just needs a little attention. 446 Haystack Drive, Newark, DE 19711 (302) 731-1456 or (610) 804-7393 amassageforfitness@verizon.net
