EmailMe Form - Client Intake Questionnaire

Name *

First Last

Date

MM / DD / YYYY

Address

Street Address City State / Province / Region Postal / Zip Code Country / Region

Email Address

(Email addresses will not be used for any other purpose or be distributed or sold to any third party.)

Date of Birth

MM / DD / YYYY

Home Phone

### - ### - ####

Work Phone

### - ### - ####

Cell Phone

### - ### - ####

Who may we thank for referring you?

Are you under a physician’s care?

Yes

No

If yes, explain:

Have you had any surgeries in the last month?

Yes

No

If yes, explain:

Are you taking any medications?

Yes

No

If yes, list medications and/or conditions associated with medications:

Do you have any allergies? If so, please list:

Have you ever received a professional massage?

Yes

No

Are you pregnant?

Yes

No

Please check all those that apply:

If there are other choices not listed that apply to you and need mentioning, list here:

Is there a specific body area on which you would like the therapist to concentrate?:
(example: shoulders, neck, low back, etc.)

What results would you like to achieve?

Have you received any other treatment for your condition?

If there are other choices not listed that apply to you and need mentioning, list here:

I understand that this is a professional massage/reflexology session and is in
no way, sexual in nature. If the practitioner feels that any inappropriate gestures are made by the client, he/she reserves the right to end the session immediately, with payment due in full.

I understand that Massage and Reflexology are compliments to healthcare and not a substitute for medical supervision of any condition. If I have any medical condition that requires a physician’s care, I have consulted him/her regarding receiving a Massage/Reflexology treatment, and either have their consent, or have taken responsibility for the session upon myself. I certify that the above information is correct to the best of my knowledge. I will not hold my massage therapist or any members of his/her staff responsible for any errors or omissions that I may have made in the completion of this form. I have disclosed all medical conditions that I am aware of and will inform my massage therapist of any changes in my health status.