Sixth World - Massage Therapy
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New Client Intake Form

PERSONAL AND HEALTH HISTORY INFORMATION INTAKE FORM – STRICTLY CONFIDENTIAL
NAME
ADDRESS
DAY-TIME PHONE
EVENING PHONE
EMAIL
BIRTHDATE
OCCUPATION
PHYSICIAN/PCP (if relevant)
EMERGENCY CONTACT
EMERGENCY PHONE
REFERRED BY

Have you had massage before? What other ways do you relieve stress?
Do you exercise or play sports? If so, what sort and how often?
Are now taking any care from a health provider for any condition?
Do you take any medications regularly, or today?
Do you have any skin problems/allergies?
Have you ever had surgery?
Have you ever had any serious injuries or illnesses?
Do you have high or low blood pressure? What was a typical recent reading? How is it controlled?
Do you have arthritis? Where?
Do you have any spinal problems/abnormalities?
Do you have any infectious/contagious conditions?
Are you experiencing any sleep disorders?
Are you pregnant? At what stage? Any complications?

Do you wear contact lenses, dentures, or hearing aides?
Do you have any other medical conditions the therapist should be aware of?
Do you have any special needs which require attention or accommodation?
Do you have any specific goals for your massage?
Are there any parts of your body that are too painful to touch, or that you would prefer not to be massaged?

I have chosen to receive massage therapy. I agree to communicate with my LMP at any times I feel my well-being is being ill-served. I understand that LMPs do not diagnose illness or injury, prescribe medication, or perform spinal thrust manipulations. I have above stated all medical conditions that I am aware of, and will update the LMP about any changes in my health status before each and every session. I agree to the policy regarding the cancellation of scheduled appointments: that no less than 24 hours notice is required or the full fee for the cancelled session may be levied at the discretion of the therapist.
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