New Client History/Intake Form — Holistic Harmony & Health

Name

First Name

Last Name

Phone Number

Emergency Contact

First Name, Last Name, Phone Number, Relationship

Employer

Occupation

Birthdate

YYYY

Have you had a professional massage before?

Yes

What type of massage are you seeking?

Relaxation

Therapeutic/pain relief

Prenatal

What type of pressure to you prefer?

Light

Medium

Deep

Do you have any allergies or sensitivities?

Are there any areas you do not want massaged?

such as feet, face, abdomen, etc.

What are your goals for this treatment session?

Are you taking any medications?

If yes, please list

Are you currently pregnant?

Yes

Do you suffer from chronic pain?

If yes, please explain. What makes it better, what makes it worse?

What types of physical activity do you regularly participate in?

Have you had any orthopedic injuries or surgeries?

If yes, how recent were they?

Do you have any other conditions or details of conditions mentioned?

This information is only seen my Michelle Edwards- the Therapist whom you are seeking treatment from.

I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time.

Yes

CONSENT STATEMENT: I give permission to my therapist to perform the scheduled treatment session as we have discussed. I will hold her and her staff harmless from any liability that may result from this treatment. I have given an accurate account of the questions asked above including all known allergies or prescription drugs I am currently taking. I understand my Licensed Massage Therapist will take every precaution and measure to give the most appropriate and therapeutic service for my current conditions. I agree this constitutes full disclosure and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand the above statements and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold my Licensed Massage Therapist responsible for any of my conditions that were present, but not disclosed at the time of service, which may be affected by the treatment performed today. This is a Therapeutic Massage session and any sexual remarks or advances will terminate the session immediately and I will be liable for payment of the scheduled treatment. I understand the Massage Therapist reserves the right to refuse services for any reason which she deems necessary.

Please sign your complete name as your signature to agreement of these terms.

Massage Therapy Client History and Consent Form