Todays

Date:





Your information:
Name:
Address:
City:
State:

Zip:

Date of Birth:



Phone:




Do I have your permission to leave
messages at this number? Yes No

Phone:

Emergency contact:
Name:

General health: Please check any that you have experienced or are experiencing, describe as needed:

Past Ongoing Details:
Allergies


_________________________________________________________________________
Skin conditions


_________________________________________________________________________
Arthritis


_________________________________________________________________________
Osteoporosis


_________________________________________________________________________
Other muscle/joint


_________________________________________________________________________
Fibromyalgia


_________________________________________________________________________
Numbness or tingling


_________________________________________________________________________
Other nervous system


_________________________________________________________________________
Cardiovascular cond.


_________________________________________________________________________
Respiratory conditions


_________________________________________________________________________
Stroke


_________________________________________________________________________
Diabetes


_________________________________________________________________________
Cancer


_________________________________________________________________________
Digestive cond.


_________________________________________________________________________
Immune system cond.


_________________________________________________________________________
Kidney or urinary cond.

_________________________________________________________________________
Pregnancy


_________________________________________________________________________
Reproductive cond.


_________________________________________________________________________
Headaches


_________________________________________________________________________
Other:


_________________________________________________________________________
Other:


_________________________________________________________________________
Other:


_________________________________________________________________________

On a scale from 0(worst) - 10(best) rate the usual quality of your:
Sleep ______ , digestion ______, breathing ______, mood______, overall health ______, support network ______
Comments on the above:



Intake form v1.4 08.2014 Im still developing my paperwork, let me know if you have any feedback!

Injuries: Please list any significant injuries. Focus on those that bother you most. Please include:
approximate date, how you were injured, parts of your body affected, how this injury still affects you, and
any diagnoses and/or treatment you have received.





















Surgeries: Please list any surgeries. Include approximate date, location, associated diagnoses, challenges or
complications during surgery or recovery, any lingering pain or discomfort, and any follow-up treatment
you have received.

Intake form v1.4 08.2014 Im still developing my paperwork, let me know if you have any feedback!

Current pain: Please label areas where you currently feel pain (P), stiffness (S), numbness or tingling (N).
Draw a circle around each letter to show the size and shape of the area. Rate the intensity in each area on a
scale of 1-10. As a rough guide, mark between 1 and 3 if the issue is noticeable but does not affect your
activity, 4-6 if it requires some modification or limitation of activity, 7-10 if it prohibits activity

Your goals for treatment: Please write a little about your goals for our work together.









Consent and contract for care: Please read carefully and sign if you consent
I am choosing to receive massage therapy, and I give my consent to receive treatment. I have shared all
health conditions that I am aware of, as well as any other information I know to be relevant. I will inform
my practitioner of any changes in my health. I will participate as fully as I am able in my treatment. I will
make sound choices about my treatment plan based on the information provided by my practitioner and
other health care providers, and my experience of those suggestions. I agree to participate in the self-care
program we select. I will inform my practitioner any time if I feel my well-being is threatened or
compromised in the course of treatment. I expect my practitioner to provide safe and effective treatment.


Signature______________________________________________________________________________
Date_________________

Intake form v1.4 08.2014 Im still developing my paperwork, let me know if you have any feedback!