CLIENT RECORD

Please print clearly and complete both sides of this form. This information is critical to your treatment, as it may affect the structure and focus of your session. All information disclosed will be kept strictly confidential.
Name: Date:
Phone: Email Address:
Check here if you do not wish to be added to my low-traffic announcement list.     
Date of birth: Occupation:
Address (please include city, state and zip code):
What is your main physical activity at work?
On phone Computer work Lifting Sitting Standing Driving
Other:
Please describe your exercise habits:
Have you ever had therapeutic massage before?
Yes No Many times
Please select any painful or tense areas, as well as regions where you tend to hold your stress:
Frequest headaches Backaches Tense shoulders/Stiff neck Upset stomach Leg/foot cramps
Other:
Please describe any recent injuries or medical conditions:
Please list any medications that you take:
GENERAL MEDICAL SIGNS AND SYMPTOMS
Please indicate if you currently have any of the following conditions
Symptom Yes No Location: Please describe
1. Any areas of infection?
2. Any areas of swelling, edema or tendency to swell?
3. Any areas of numbness or abnormal sensation?
3. Any areas of pain or tenderness?
SPECIFIC MEDICAL CONDITIONS
For your safety, I must be aware of all medical conditions for which you have been diagnosed. Therapeutic massage may impact these and your health.
Symptom Yes No Location: Please describe
5. Arthritis:
6. Cancer or Tumors:
7. Cardiovascular diseases: Please check all that apply:
Anemia Angina Arteriosclerosis Congestive Heart Failure Heart Attack Heart Murmur Hemophilia Hypertension/High blood pressure Varicose or Spider Veins
Other:
8. Diabetes:
9. Injuries:
10. Kidney or Liver Disease:
11. Respiratory or Lung conditions:
12. Skin conditions: Please check all that apply:
Acne Abrasions / Cuts Bruises Dermatitis Eczema Herpes Hives Poison ivy/oak/sumac Psoriasis Skin tags Sunburns Warts
Other:
13. Other medical conditions:

I understand that the massage I receive is provided for the basic purpose of relaxation, stress reduction and relief of muscular tension. If I experience any pain during this session, I will immediately inform the practitioner so that the work can be adjusted to my level of comfort.

I further understand that massage/bodywork should not be used as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment that I am aware of.

Because massage can be harmful under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly I agree to keep the practitioner updated as to any changes in my medical profile, and understand that there shall be no liability on the practitioner's part should I forget to do so.

It is also understood that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment for the full scheduled appointment.

Should I need to cancel future sessions, I agree to give my practitioner 24 hours notice or I will be financially responsible for the session time.
Signed: Date:
This intake form is copyright (c) 2006 Abi Harper Massage.
If you would like to adapt this form for your own practice, please contact Abi directly at 617-797-6995.