The Muscle Mender

1121 Charlotte Avenue, Rock Hill, SC 29732 Sioux Forsyth, LMBT 6229

Condential Client Intake Form

Please complete this form front and back legibly. All information is condential.

Name:_________________________________________ DOB:______ Gender:____ Street:______________________________City:______________State & Zip:______ Telephone (H):_____________________(C)________________(W):____________________ Email:_________________________________ Occupation:_____________________Daily Activities:________________________1 Emergency Contact:_____________________________Phone:___________________ Previous Massage: Y N Any problems:_________________________________ Are you under medical supervision? _________________________________________ General Physician:____________________________Phone:_____________________ Primary reason for massage: pain relief relaxation Do you exercise? Y N Y N sports performance

How often/duration?_____________ Do you smoke?

How did you hear about me?_______________________________________________ List any allergies?________________________________________________________ List any medications:_____________________________________________________

Circle all that apply: Allergies Cancer Pregnant Stroke heart condition arthritis diabetes infection blood clots bruise easily kidney disorder

inammation

previous MVA/trauma ruptured/bulging disk seizures High Blood Pressure spondylolysthesis

surgery varicose veins

HIV positive contagious/infectous conditions Are you pregnant? Y N Describe areas of pain or areas you would like me to concentrate on: ________________________________________________________________________

Please read and sign: The information that I have provided is accurate so as to better assist the massage therapist to understand and to determine my particular healthcare needs. Because this completed client intake form will not be repeated during future visits, I will keep the massage therapist informed of any changes in the information. I understand that I should inform the therapist any time that I feel pain or am uncomfortable. I understand that there is a 24 hour notice of cancelation. If I fail to notify the therapist of cancelation 24 hours prior or do not arrive for an appointment I agree to pay a $25.00 fee for her time. I understand that both, myself and the therapist, reserve the right to terminate this therapy session at any time if either feels uncomfortable for any reason. I acknowledge that the licensed massage therapist observes and operates by a code of ethics and professionalism. This massage is intended for therapeutic purposes only.

Signature:______________________________________________Date:___________