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Do you have any of the following conditions? (please check the left box for all that apply)
Example conditions: Neck Pain, High Blood Pressure, Fibromyalgia, Headaches, Back Pain and Scoliosis.
Cancer: Are you or have you ever been treated for cancer? If so, please describe.
Injury history: Injury History in the last 5 years, for example car accidents, broken bones, dislocations and falls.
Medical profile: I agree to keep the therapist updated as to any changes in my medical profile.
Physician's care: I understand the massage services are designed to be a health aid and in no way substitute a physician's care when indicated.
| Question | Answer |
|---|---|
| Form Name | Massage Therapy Client Intake Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 3 min |
| Other names | Massage Therapy Client Intake Form, Intrinsic Touch intake form, massage client intake form, massage intake form, massage health history form |
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