Client Intake Form

Client Intake Form

Please fill out all information as accurately and thoroughly as possible. It is better that you give me what you consider too much information, rather than not give me enough information. Thanks!
Name*

First NameLast Name
Cell Phone*

Area CodePhone Number
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Email*
example@example.com
Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
How did you hear about Take 5 Bodywork?*
Profession
Hobbies/Exercise/ Frequent Activities
In Case of Emergency
Contact's Name

First NameLast Name
Relationship to Me
Contact's Phone

Area CodePhone Number
General Health History
Covid-19 Vaccine:*
Are you pregnant?

YesNoWe are tryingUnsure
If pregnant, how far along at this time?
List any surgeries you have had, why, and their approximate dates:*
(e.g., achilles tendon reattachment after tennis injury - April 2012)
List any recent or chronic injuries:*
(e.g., my back periodically goes out; herniated L4 disc...)
List any Health Problems (e.g., blood pressure, asthma, seizures, headaches, illness...):*
List any mental, emotional, psychological issues (e.g., ADHD, Bipolar, depression, Schizophrenia...)*
List any allergies (e.g., seasonal, peanuts, eucalyptus oil...):*
List any other issues (e.g., digestive, skin, structural, skeletal...)*
List any medications or supplements taken regularly and what for:*
Do you have any conditions that may require a doctor's note or that you are unsure may be indicated for massage? Please list.
Name of your physician/health care provider:
Dr.'s Phone:

Area CodePhone Number
If the need should arise, may I contact your healthcare provider?
Session Notes
What (specifically) would you like to receive from this massage?
(e.g., relaxation, pain relief, reduce edema, improve digestion...)
Are there any areas you'd like the massage therapist to focus on?
(e.g., My neck and shoulders are very tight, please incorporate energy work...)
Are there any areas you'd like the massage therapist to avoid or be cautious of?
(e.g., My feet are ticklish, I don't like my ears rubbed, my calves are sensitive...)
Do you have pain or tension? Please describe...

Where is it? How long has it been bothering you? Are there any specific movements you make that illicit the pain? Can you describe the pain? (Is it dull, achy, sharp, shooting, electrical, numbing, throbbing, intermittent, constant, pulsing...?)
Describe pain here:
(e.g., Sharp pain upon turning my head to the left started Monday when I woke up...)
Anything else we need to know?
Other Notes/ Comments:
(e.g., I don't like table warmers. I've never had a massage before...) Or use this area to continue a note if you ran out of room above.
Person completing form:*

I am the client and over age 18.I am a parent or legal guardian of the client.Other
By submitting this form, you agree to the following:

"I attest that the above information is accurate and true to the best of my knowledge. I understand that a massage therapist is not a doctor and cannot prescribe medications, diagnose medical conditions, or manipulate bones. The therapist reserves the right to end any session in the case of sexual innuendo or advances from the client. I accept the responsibility for clearly communicating my needs and limitations at all times and for alerting the therapist to any physical, mental, or emotional changes that occur with my health. I hold the therapist harmless in any event.

"I also understand that cancelled or missed appointments without 24 hours advanced notice will be charged a missed session fee and that arriving late to my appointment may result in a shorter session."
Entering your name here suffices as a signature on this form and confirms that you have read and agree to the above statement.*

First NameLast Name
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Client Intake Form

In Case of Emergency

General Health History