Online CE & MTI
New Client Intake Form
Please complete this form prior to your first appointment:
MM slash DD slash YYYY
Date of Birth
MM slash DD slash YYYY
Address Line 2
District of Columbia
Northern Mariana Islands
U.S. Virgin Islands
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
In case of emergency contact
In the event we need to contact you regarding an appointment, which would you prefer?
Basic Health Information
posture assumed most of the day
How often do you exercise?
Type of exercise
Height and Weight
What are primary stressors
Are you basically in good Health
Has there been any significant change to your health in the past year?
Are you happy with your general energy level?
Do you use any of the following regularly?
other recreational drugs
Please indicate if any of the following apply"
pins, plates, artifical joints
List medications, herbs, drugs:
What is your goal or concern for today's session?
Indicate any of the following that apply in the last 6 months
blood pressure elevated
blood pressure low
persistent cough (esp the last 14 days)
eye infections, such as pink eye, conjunctivitis
fever over 101 (esp the last 14 days)
fungal infections, such as athlete's foot, thrush
loss of sense of taste or smell (esp last 14 days)
rashes (esp in last 14 days)
vomiting/nausea/diarrhea (last 14 days)
lotion, cream, oil allergies
Consents and Acknowledgments
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 fail to do so.
Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I understand I may be asked for a referral from my primary care provider prior to service being rendered if determined necessary by my therapist.
I realize it is my choice to receive massage therapy. I acknowledge that the treatment is being given for the well-being of my body and mind. This includes stress reduction, relief from muscular tension, spasm or pain, increasing circulation, energy or lymphatic flow, or increasing mobility.
I acknowledge that massage is not a substitute for medical examination or diagnosis, and that it is recommended that I see a primary health care provider for that service.
I understand that massage practitioners do not diagnose illness, disease, or any physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals, or perform spinal thrust manipulations.
Release of Information
I hereby authorize you to release to the practitioner named below any information necessary to provide the best care and collaboration.
I hereby authorize you to release to any physician or practitioner or the practitioner named below any medical or other records or information necessary to provide the best care and collaboration. These records are to be utilized for the coordination of care.
Name of Practitioner
Acknowlegment for Client and Practitioner Safety
I agree to abide by any and all safety practices implemented by my therapist.
I have been informed of the precautions taken by my therapist to ensure a safe clean environment for my session. I have read the COVID-19 information found on this website. I realize I will be required to answer a series of questions before each session to ensure a safe session for myself and my therapists. I attest that my answers are truthful, trust my therapist to assess all the other clients for safety, and hold harmless my therapist in the event I contract COVID as a result of a session.
I agree to the financial policy.
I agree and acknowledge that I am responsible for payment of any balance due upon completion of each session unless prior arrangements are made. I understand that emergencies do arise that can result in missing an appointment. Please notify your practitioner as soon as possible if you will miss an appointment. There is no penalty for an infrequent late cancellation or missed appointment. If I fail to cancel two consecutive appointments, I will be responsible for payment of the full fee for both missed appointments prior to rescheduling another appointment.
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