Client Intake Form Name___________________________________________ Date________________________ Are any of your joints painful when moving them? Yes No If yes, please explain___________________________________________________________ If this is a return visit, have any of these conditions changed since your last massage? High blood pressure Varicose veins Pregnancy / painful menstration Bruising Thrombosis/Phlebitis Swelling Localized infections/ open wounds Fever Fracture(s) / painful joints Medications Skin problems / rash Illness / Diseases Headaches Injuries Trauma / wounds Nut Allergy If you checked any of the above conditions or if you have a condition not listed above, please explain: Please circle on the diagram below that you feel need extra work. Cross out any areas you would like to be avoided. Preferred Pressure (circle one): Light Medium Deep ??? Signature: ____________________________________________________
Client Intake Form Name___________________________________________ Date________________________ Are any of your joints painful when moving them? Yes No If yes, please explain___________________________________________________________ If this is a return visit, have any of these conditions changed since your last massage? High blood pressure Pregnancy / painful menstration Thrombosis/Phlebitis Localized infections/ open wounds Fracture(s) / painful joints Skin problems / rash Headaches Trauma / wounds Varicose veins Bruising Swelling Fever Medications Illness / Diseases Injuries Nut Allergy If you checked any of the above conditions or if you have a condition not listed above, please explain: Please circle on the diagram below that you feel need extra work. Cross out any areas you would like to be avoided. Preferred Pressure (circle one): Light Medium Deep ??? Signature: ____________________________________________________