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    Client Intake Form

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    api-162312216
    This confidential intake form collects information about a new client's personal details, medical history, goals for their appointment, and any physical issues or conditions. Key details include the client's name, date of birth, contact information, emergency contact, prior experience with touch therapy, reason for their appointment, openness to receiving energy work, current medical treatments, recent life changes, current physical issues, medications/supplements, and an understanding that the massage therapist does not diagnose or prescribe treatment.

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    Client Intake Form

    Uploaded by

    api-162312216
    89 views1 page
    This confidential intake form collects information about a new client's personal details, medical history, goals for their appointment, and any physical issues or conditions. Key details include the client's name, date of birth, contact information, emergency contact, prior experience with touch therapy, reason for their appointment, openness to receiving energy work, current medical treatments, recent life changes, current physical issues, medications/supplements, and an understanding that the massage therapist does not diagnose or prescribe treatment.

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    client intake form

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    This confidential intake form collects information about a new client's personal details, medical history, goals for their appointment, and any physical issues or conditions. Key details include the client's name, date of birth, contact information, emergency contact, prior experience with touch therapy, reason for their appointment, openness to receiving energy work, current medical treatments, recent life changes, current physical issues, medications/supplements, and an understanding that the massage therapist does not diagnose or prescribe treatment.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    89 views1 page

    Client Intake Form

    Uploaded by

    api-162312216
    This confidential intake form collects information about a new client's personal details, medical history, goals for their appointment, and any physical issues or conditions. Key details include the client's name, date of birth, contact information, emergency contact, prior experience with touch therapy, reason for their appointment, openness to receiving energy work, current medical treatments, recent life changes, current physical issues, medications/supplements, and an understanding that the massage therapist does not diagnose or prescribe treatment.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    of 1

    Confidential Client Intake Form

    Name: ____________________________________________________

    D.O.B. _____/_____/_____

    Address: ______________________________City: _____________ State: _______ Zip: ____________


    Home Phone: ________________________________ Cell/Work: _______________________________
    E-Mail: _______________________________________ Occupation: ____________________________
    Emergency Contact: __________________________ Phone: __________________________________
    Do you have prior experience receiving professional touch therapy? Y/ N
    If yes, please explain and share frequency? __________________________________________________
    _____________________________________________________________________________________
    What is your Primary Reason/Goal/Focus for todays appointment?_______________________________
    _____________________________________________________________________________________
    Are you open to receiving Reiki (energy work) as a part of todays session? Y/N
    Are you currently receiving treatment from a physician or another health care provider? Y/N
    If yes, please explain: ___________________________________________________________________
    Have you experienced a significant life change recently or at present? Y/N If yes, please explain:
    _____________________________________________________________________________________
    Do you have any issues you would like to bring to my attention regarding your present experience? Y/N
    _____________________________________________________________________________________
    Please circle that which applies to your current experience and/or past:
    Surgery

    Accidents

    Varicose Veins

    Injury Hospitalization Inflammation

    Skin Rash/Cut/Bruise

    Spinal/Joint issues

    Arthritis

    Medications/Herbs/supplements

    Cold/Flu

    Chronic Pain
    PMS

    Cancer HIV/AIDS

    Allergies

    Pregnancy (term _____ )

    Back/Neck/Shoulder pain

    Blood Pressure High/Low

    Diabetes
    Headaches

    Please expand upon that which has been circled and list other conditions, issues and medications not
    listed above:__________________________________________________________________________

    I, ___________________________________ understand that treatment given here is for the purpose of


    promoting relaxation, increased energy flow, clarity, self awareness, and health building balanced energy.
    I understand that Massage Therapists do not diagnose illness, disease or any physical or mental disorders.
    I understand that Massage Therapists do not prescribe medical treatment or perform spinal manipulation.
    I take responsibility for informing my practitioner of any physical, mental or emotional changes that
    occur with my health.

    Client Signature: ________________________________________ Date: __________________

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