Client Intake Form
Client Intake Form
Step
1
of
2
50%
Credit Card
(Required)
Cardholder Name
Card Details
Session Length
(Required)
60 Minute
90 Minute
120 Minute
50% of the appointment fee will be authorized to reserve your appointment slot. Your card will not be charged unless you late cancel or no show.
Total
Name
(Required)
First
Last
Phone
(Required)
Email
(Required)
Emergency Contact Name
(Required)
First
Last
Emergency Contact Phone
(Required)
Consent
I agree for my therapist to follow up with me to ensure my satisfaction with my massage experience
Preferred form of communication
(Required)
Phone Call
Text
Email
Select All
Would you like email updates from Lime Green Lotus, e.g. on new services and special offers/discounts?
(Required)
Yes
No
Section Break
The following information will be used to help plan safe and effective massage sessions. Please answer the following questions to the best of your knowledge.
Have you had a professional massage before?
(Required)
Yes
No
If so, how often?
(Required)
Do you have any difficulty lying on your front, back or side?
(Required)
Yes
No
If so, please explain.
(Required)
Do you have sensitive skin or allergies to oil, lotion, or ointment?
(Required)
Yes
No
If so, please explain.
(Required)
Do you sit for long hours at work or driving, or perform any repetitive movement in your work, sports, or hobbies?
(Required)
Yes
No
If so, please describe.
(Required)
Do you experience stress in your work, family or other aspects of your life?
(Required)
Yes
No
If so, how do you think it has affected your health
(Required)
Muscle tension
Anxiety
Irritability
Other
Define "other"
(Required)
Is there a particular area of the body where you are experiencing tension, stiffness, pain or other discomfort?
(Required)
Yes
No
If so, please identify
(Required)
Do you have any particular goals in mind for this massage session?
(Required)
Yes
No
If so, please describe
(Required)
Medical History
Are you currently under medical supervision?
(Required)
Yes
No
If so, please explain.
(Required)
Do you see a chiropractor?
(Required)
Yes
No
If so, how often?
(Required)
Are you currently taking any medications?
(Required)
Yes
No
Check all that apply
(Required)
Coumadin
Lovenox
Heparin
Plavix
High-dosage aspirin or ginger
Pain killers
Muscle relaxants
Other(s)
Please list any other medications
(Required)
Do you have (check all that apply)
(Required)
None
Phlebitis/Deep vein thrombosis/Blood clot/Varicose veins
Heart condition (pacemaker?)
Joint disorder/Rheumatoid Arthritis/ Osteoarthritis/Tendonitis
Osteoporosis
Open sores or wounds
Current fever, flu, cold or swollen glands
Recent accident or injury (specify)
Artificial joint
MRSA or other infectious diseases
Epilepsy
Headaches/Migraines
Neuropathy (decreased sensation)
Atherosclerosis
Scoliosis or lordosis; herniated discs (where?)
Hemorrhoids
Aneurism
High or low blood pressure (controlled?)
Fibromyalgia
Easy bruising
Contagious or inflammatory skin condition, cellulitis, boils, skin lesions or abscesses
Surgery within the last year or implants within the last nine months (cheek, chin, breast, pectoral, calf)
Sprain/Strain/Fracture/Break
Carpal tunnel
Tennis/Golfer’s elbow
TMJ
Cancer (cancer medication?)
Diabetes
Pregnancy (which trimester?)
Circulatory disorder
Kidney or liver disorder (including dialysis)
Lumbar spinal stenosis, spondylitis or spondylolisthesis
Irritable bowel syndrome
Specify your recent accident or injury
(Required)
Where is your scoliosis or lordosis; herniated discs?
(Required)
Is your blood pressure controlled?
(Required)
Are you on medication for your cancer?
(Required)
Which trimester is your pregnancy?
(Required)
Is there anything else about your health history that is important to plan a safe and effective massage session for you and your massage therapist?
(Required)
Consent
A parent or legal guardian must accompany clients under the age of 18 and provide informed written consent.
Consent
I understand that the massage I receive is provided for the basic purpose of relaxation and
relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or stroke may be adjusted to my level of comfort. I further understand that the massage should not be construed as a substitute for medical examination, diagnosis or treatment. I understand that massage therapists are not licensed to perform spinal or skeletal adjustments, diagnose, prescribe or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage 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 agree to keep the therapist updated as to any change in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so.
Full Name
(Required)
Type your full name to serve as your signature
Today's Date
(Required)
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