Client Forms
Intake/Health History Form (to be filled in prior to massage)(to print: highlight all and print)
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____________________________