Client Intake Form

    
   

Please fill out this form as completely and accurately as possible. It is better to provide too much information than not enough. All information provided on this form, as well as any provided during sessions, will be held in confidence.

* indicates a required field.

  
 

 

 
 
Name*:
  
 
Street Address *:
  
 

City*:

 State*: Zip*:  
 
Best Contact Phone*:
  
 
Alternate Phone*:
  
 
E-mail Address*:
  
 
Year of Birth*:
  
 
Occupation*:

 
 
Gender*:
 Female Male  
 
Emergency Contact Name*:
  
 
Emergency Contact Phone*:
  
 
Who Referred You:

 
 
What is the primary reason you are seeking massage or wellness services?
  
 
How severe is the problem on a scale of 1-10? (0 = No Problem; 10 = Most Severe):

 
 
Current Health Issues – Please describe any health conditions which you have NOW.

Allergies*:

Injuries*:

Recent Surgeries*:

Diseases*:

Chronic Health Concerns*:

  
 
Health History - Please describe any significant health conditions which you have had in the PAST, with approximate dates.

Injuries:

Surgeries:

Diseases:

  
 
Treatment you are currently receiving for disease, injury, or health maintenance*:
  
 
On average, how many minutes per day do you get moderate to vigorous exercise?

 
  Do you have any of the following*:

Pacemaker
Yes No

Implanted Defibrillator
Yes No

Intravenous Port
Yes No

Bleeding Disorder
Yes No

Easy Bruising
Yes No

 
  For Female Clients:  Are you pregnant, or is there a chance you might be pregnant*? Yes No  
  For Female Clients:  Have you experienced or are you experiencing menopause*? Yes No  
   

PRIVACY POLICY: Sunflowers Massage and Wellness LLC and Susan Lynx RN respect your privacy. Your personal data and health information are never shared with anyone else without your express written consent, unless required by applicable law. This includes written, verbal and electronic data.

CONSENT FOR MASSAGE AND DISCLAIMER

By submitting this information, I agree that:

  • I have read and understood the Privacy Policy.
  • The information I have provided is true and accurate to the best of my knowledge.
  • I have stated all my known health conditions. I will inform the massage provider of any change in my health status.
  • I acknowledge that massage therapy, acupressure, Tuina, craniosacral therapy, cupping, stretching and exercise are not substitutes for medical examination or medical care.
  • I acknowledge that the provider will end the session in the case of sexual innuendo or advances from the client.
  • It is my choice to receive massage, acupressure, Tuina, craniosacral therapy, cupping, stretching consultation/instruction, or basic exercise instruction. I am aware of the benefits and risks, and I give my consent for these services.