Client Intake Form | From Me to You Massage Therapy

Name *

Phone *

Date of Birth *

Month *

Day *

Year *

Street Address *

Apartment, suite, etc

City *

State *

ZIP Code *

Referred By

Email Address *

Occupation

Emergency Contact *

Emergency Contact Phone *

Have you had a professional massage before? *YesNo

If yes, how often do you receive massage therapy?

Do you have any difficulty lying on your front, back, or side? *YesNo

If yes, please explain

Do you have any allergies to oils, lotions, ointments or scents? *YesNo

If yes, please explain

Do you have sensitive skin or bruise easily? *YesNo

If yes, please explain

Are you wearing any of the following?Contact LensesDenturesHearing AidPlease check each item you are wearing.

Do you sit for long hours at workstation, computer or driving? *YesNo

If yes, please explain

Do you perform any repetitive movement in work, sport or hobby? *YesNo

If yes, please explain

Do you experience stress? *YesNo

Is there a particular area of the body where you are experiencing tension, stiffness, pain or other discomfort? *YesNo

If yes, please identify

What are your massage goals? *

Are you currently under medical supervision? *YesNo

If yes, please explain

Are you currently taking any medications? *YesNo

If yes, please list

Please explain any condition checked.

Is there anything else about your health history that you think would be useful for your massage therapist to know to plan a safe and effective massage session for you?

What kind of pressure do you prefer? *LightMediumFirm

List and prioritize your current symptoms/issues *

If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage/bodywork 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 of which I am aware. I understand that massage/bodywork practitioners are 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 massage/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 understand and voluntarily accept any risks of which I have been advised about and associated with my massage/ bodywork, of from any use of the company’s facilities, and hereby release the following therapists/practitioners and entities: Courtney Dortch-Pickens, LMT- From Me To You Massage Therapy LLC, from all liability for any injury, including, without limitation, personal, bodily or mental injury, from all liability arising from any such injury or damage resulting from my failure to disclose any pre-existing condition, determine that it is unsafe for me to proceed with or continue a therapeutic session due to health related concerns. In this event I must provide the therapist/practitioner with a physician’s medical release prior to continuing treatment. I agree to keep the therapist/practitioner updated as to any changes in my medical profile. 12-hour advance notice is required when cancelling an appointment. If you are unable to give us 12-hour notice you will be charged/billed full amount of your appointment. This amount must be paid prior to your next scheduled appointment. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. Understanding all of this, I give my consent to receive care. *

Client Signature *

Today's Date *

Parent or Guardian Signature (in case of a minor)

Today's Date