Client Intake & Medical History
Please complete this form before your appointment so I can better understand your health history and treatment goals. Your information is kept private and confidential.
1. Client Information
Full Name
Date of Birth
Phone Number
Email Address
2. Emergency Contact
Contact Name
Phone Number
3. Insurance Information
Insurance Carrier, Member ID, and Claim/Authorization Number (if applicable)
4. Reason for Visit
Main concern (short answer)
Primary area(s) of concern
Duration of symptoms (Days / Weeks / Months / Years)
5. Medical History
[ ] Recent injury or surgery (last 12 months)
[ ] Chronic pain condition
[ ] Migraines/headaches
[ ] Cardiovascular conditions (heart disease, stroke, high blood pressure)
[ ] Diabetes
[ ] Neurological conditions (neuropathy, seizures, nerve disorders)
[ ] Autoimmune conditions
[ ] Pregnancy
[ ] Cancer history
[ ] Blood clotting disorders
[ ] None of the above
6. Surgical / Injury History
List any relevant surgeries, injuries, accidents, or medical devices (with dates if known).
7. Massage & Comfort Preferences
Preferred pressure level, areas you would like addressed, areas you prefer to avoid, or anything else that would help make your treatment comfortable.
8. Consent for Treatment
[ ] I understand massage is for therapeutic purposes and does not replace medical care.
[ ] I agree to provide accurate health information and update changes before sessions.
[ ] I understand treatment may be modified or stopped for safety reasons.
9. HIPAA Privacy Acknowledgment
By signing below, I acknowledge that I have been informed of my rights to privacy regarding my protected health information (PHI) under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that this information can and will be used to plan and direct my treatment and follow-up, obtain payment, and conduct normal healthcare operations.
10. Signature
Signature
Date