Client Forms

Client Feedback form

 

Intake/Health History Form (to be filled in prior to massage)

Sandra Swanson, LMT

Intake/Health History

 

Name_______________________________      Phone Number_________________

Address________________________________________           Date____________

 

Why are you here?____________________________________________________

Has any doctor or any health practitioner ever advised AGAINST receiving a massage?____

Have you ever had a massage?______ If yes, what did you like/dislike about it?_______________________________________________________

How did you get my name?__________

Do you have, or have you had, any of the following:

 

Circulatory issues______________________________________________________

Heart issues__________________________________________________________

Headaches___________________________________________________________

Skin issues___________________________________________________________

Joint issues___________________________________________________________

Bone issues__________________________________________________________

Ligament/Tendon/Muscle issues__________________________________________

Nervous System issues_________________________________________________

Allergies/Sensitivities__________________________________________________

Disability___________________________________________________________

Specific Organ issues__________________________________________________

Respiratory issues____________________________________________________

Mental-health issues__________________________________________________

Injury_____________________________________________________________

Autoimmune issues___________________________________________________

Surgery____________________________________________________________

Any disease and/or any/all issues to relay to a health practitioner____________________ 

Describe any pain (shooting, deep, Constant/frequency, etc.)

___________________________________________________

Are there any areas that you want me to avoid?______________ 

Are there any areas that you want me to concentrate on?______________

Are you on any medication?_________

 

Emergency Contact_______________________

Signature____________________________

 

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