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MASSAGE NEW CLIENT INTAKE FORM
Please complete prior to services appointment
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Indicates required field
Name
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First
Last
Date
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Address
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City
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State
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Zip Code
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Home Phone
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Work Phone / Cell
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Date of Birth MM/DD/YYYY
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Occupation
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Emergency Contact
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Emergency Contact Phone
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MASSAGE INFORMATION
How did you hear about us?
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It helps us to know if you were referred or found us on the web.
Service booked with us
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Ex: 1-hour relaxation massage
Massage History
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Choose an answer from the dropdown
This is my first time for a professional massage..
I've had a professional massage before.
Date of Last Massage (if applicable)
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What do you want to gain from your session?
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List any stress reduction, (EX: exercise) and the frequency
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List any stress reduction you use now as well as the frequency. If none just state none.
DAY of APPOINTMENT - ADVISE IF....
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Wearing Contact Lenses
Have an Infection
Experiencing Swelling
Have a Fever
Have Communicable Illness
None of the above
Check all that apply on the day of your appointment - if filling out this form ahead of your appointment, fill it out to the best of your ability - please make therapist aware of any of these items on the day of your appointment.
MEDICAL HISTORY
List any current medications you are taking, including aspirin, ibuprofen, herbal, etc.
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Injuries/ accidents still affecting you and date
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Surgeries and dates
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Major illness or hospitalizations and date
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CONDITIONS
Check all that apply
MUSCULOSKELETAL
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TMJ/Jaw Pain
Neck/Shoulder/Arm Pain
Low Back/Hip/Leg/Knee Pain
Bone/Joint Disease
Osteoporosis
Sprain/Strain
Spasms
Tendonitis/Bursitis
Lupus
None of the above
Check all that apply. Use Notes or Other section at end if specifics are necessary.
SKIN
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Allergies
Rashes
Athletes Foot
Herpes/Cold Sores
None of the above
Check all that apply. Use Notes or Other section at end if specifics are necessary.
NERVOUS SYSTEM
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Shingles
Numbness/Tingling
Trigeminal Neuralgia
Pinched Nerve
None of the above
Check all that apply. Use Notes or Other section at end if specifics are necessary.
REPRODUCTIVE
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Pregnant
Ovarian/Menstrual Problem
PMS
Prostate Problem
IUD
None of the Above
Check all that apply. Use Notes or Other section at end if specifics are necessary.
CIRCULATORY
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Thrombosis/Embolism
Heart Condition
Phlebitis/Varicose Veins
Blood Clots
Lymphedema
High/Low Blood Pressure
None of the above
Check all that apply. Use Notes or Other section at end if specifics are necessary.
RESPIRATORY
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Asthma/Breathing Difficulty
Emphysema
Allergies
Sinus Problem
None of the above
Check all that apply. Use Notes or Other section at end if specifics are necessary.
NOTES
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Add any additional condition here not covered above or any pertinent information on a checked medical condition.
DIGESTIVE
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Constipation
Gas/Bloating
Diverticulitis
Diarrhea
Constipation
IBS
Ulcers
None of the above
Check all that apply. Use Notes or Other section at end if specifics are necessary.
OTHER CONDITIONS
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Cancer/Tumors
Kidney/Bladder
Diabetes
Caffeine/Alcohol Use
Tobacco/Drug Use
Depression
Chronic Fatigue
Chronic Pain
Sleep Disorder
Headaches/Migraines
Anxiety/Stress Syndrome
Other - use Notes
No Additional Conditions
Add all that apply - not previously listed. Use Notes at end if specifics are necessary.
Health Disclosure and Appointment Cancellation Policy Agreement
A massage therapist must be aware of any existing physical conditions that I have, I have listed all my known medical conditions and physical limitations and will inform the massage therapist in writing of any change in my physical health. I understand that a massage therapist does not diagnose illness, disease, or any other medical, physical, or emotional disorder, nor do they perform any spinal manipulations or claim to cure disease and illness.
I am responsible for consulting a qualified physician for any physical ailment that I have prior to seeking massage or other modality therapy from Ayaa Massage/My Lighted Life.
I have disclosed all necessary health information, understand the preparation and follow up instructions, and agree to Massage, and/or Assisted Lymphatic Therapy (ALT) treatment(s).
If I cancel within 24 hours of my scheduled appointment and, I agree to pay the full dollar amount of my appointment.
I understand I can find HIPAA disclosure information related to my healthcare through this link provided by the U.S. Dept of Health and Human Services:
www.hhs.gov/hipaa/for-individuals/index.html
I agree that by typing or signing my name on this form, and/or submitting this form that it will represent my willful and legal signature for this document, and booked therapy.
I certify that the above health history is correct, and I agree to the policies set forth within this intake document by typing or signing my name here
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Welcome
About
Services
New Client Form
Resources
Get in Touch
