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Client Intake Form

This confidential intake form collects information about a new client's personal details, medical history, goals for their appointment, and any physical issues or conditions. Key details include the client's name, date of birth, contact information, emergency contact, prior experience with touch therapy, reason for their appointment, openness to receiving energy work, current medical treatments, recent life changes, current physical issues, medications/supplements, and an understanding that the massage therapist does not diagnose or prescribe treatment.

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api-162312216
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as PDF, TXT or read online on Scribd
137 views

Client Intake Form

This confidential intake form collects information about a new client's personal details, medical history, goals for their appointment, and any physical issues or conditions. Key details include the client's name, date of birth, contact information, emergency contact, prior experience with touch therapy, reason for their appointment, openness to receiving energy work, current medical treatments, recent life changes, current physical issues, medications/supplements, and an understanding that the massage therapist does not diagnose or prescribe treatment.

Uploaded by

api-162312216
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as PDF, TXT or read online on Scribd
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Confidential Client Intake Form

Name: ____________________________________________________

D.O.B. _____/_____/_____

Address: ______________________________City: _____________ State: _______ Zip: ____________


Home Phone: ________________________________ Cell/Work: _______________________________
E-Mail: _______________________________________ Occupation: ____________________________
Emergency Contact: __________________________ Phone: __________________________________
Do you have prior experience receiving professional touch therapy? Y/ N
If yes, please explain and share frequency? __________________________________________________
_____________________________________________________________________________________
What is your Primary Reason/Goal/Focus for todays appointment?_______________________________
_____________________________________________________________________________________
Are you open to receiving Reiki (energy work) as a part of todays session? Y/N
Are you currently receiving treatment from a physician or another health care provider? Y/N
If yes, please explain: ___________________________________________________________________
Have you experienced a significant life change recently or at present? Y/N If yes, please explain:
_____________________________________________________________________________________
Do you have any issues you would like to bring to my attention regarding your present experience? Y/N
_____________________________________________________________________________________
Please circle that which applies to your current experience and/or past:
Surgery

Accidents

Varicose Veins

Injury Hospitalization Inflammation

Skin Rash/Cut/Bruise

Spinal/Joint issues

Arthritis

Medications/Herbs/supplements

Cold/Flu

Chronic Pain
PMS

Cancer HIV/AIDS

Allergies

Pregnancy (term _____ )

Back/Neck/Shoulder pain

Blood Pressure High/Low

Diabetes
Headaches

Please expand upon that which has been circled and list other conditions, issues and medications not
listed above:__________________________________________________________________________

I, ___________________________________ understand that treatment given here is for the purpose of


promoting relaxation, increased energy flow, clarity, self awareness, and health building balanced energy.
I understand that Massage Therapists do not diagnose illness, disease or any physical or mental disorders.
I understand that Massage Therapists do not prescribe medical treatment or perform spinal manipulation.
I take responsibility for informing my practitioner of any physical, mental or emotional changes that
occur with my health.

Client Signature: ________________________________________ Date: __________________

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