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Massage Intake Form For New Clients

Please be aware that the information we receive is never shared with anyone, and we abide fully by the HIPAA Laws governing how a client's private medical information should be protected.

Please fill out the below form in its entirety, including all details. This will help your therapist to better plan a session for you.

Parents, please fill out this form for your child, or if your child is under 18 and fills it out for themselves, please be present while the form is being filled out and review their answers after they're finished. Thank you!

Name: E-Mail:
Cell Phone:
Home Phone:


Birthday: Height:


If you are filling out the form for someone else, please provide your name and relation or association with the person (e.g. mother, spouse, nurse, secretary):

Please provide emergency contact details below:

Emergency Contact Name:
Phone Number:

Primary Physician Name:
Phone Number:

If you were referred by another client, please share their name:

If you found out about us in another way, please explain how you found our site: (Google search, magazine ad, etc.)

If you searched online, what search term did you use? (mobile massage, massage in home in Jersey City, at home therapist, etc.)

Please list any allergies that you may have, or have had in the past, as well as level of severity:

Please list any medications you are currently taking, and why:

Please list all surgeries that you may have had, and when you had them:

If you are presently on a special diet, either prescribed by a doctor or on your own, please describe:

If you're currently taking vitamins or supplements, please list what you're taking:

Please list any physical activity or sports & athletic training you have done recently, as well as how often you do this:

What are your goals for today's session?

Please briefly list all areas you would like the session to focus on and why:

Please rate your overall physical energy level:
1 (low) 2 3 4 5 6 7 8 9 10 (high)

Please rate your overall mental energy level, or level of focus:
0 (unfocused)
1 (low) 2 3 4 5 6 7 8 9 10 (totally focused, hyper-aware)

Please rate your overall stress level:
0 (nonexistent)

Do you use any of the following mobility aids?
Cane Walker Wheelchair Assistant Canine

Do you use wear glasses or contact lenses or have a severe vision impairment?
Glasses Contact Lenses Legally Blind

If female, and of childbearing age, are you now pregnant?
Yes No It is possible, but I do not know this for certain.

If so, how far along are you?

Please list any complications, if any exist.

Have you ever had a C-Section? Yes No
If so, how many years ago?

If you have had any recent injuries or accidents, what happened, and what was the outcome?

How are you treating this now?

Have you ever had a therapeutic massage session?
Yes No
When was the last session you had?

If you are experiencing inflammation anywhere, please provide details:

If you are in pain anywhere, please describe where.

What sort of pain? Shooting, stabbing, etc.

If you are experiencing numbness, or 'pins-and-needles' (partial numbness) anywhere, please explain.

If you are inflexible anywhere, please state where this is happening.

If you have any known joint issues, please state which joints are involved.

If you have an autoimmune condition contributing to any of this, please explain.

If you have any learning issues such as dyslexia, ADD, ADHD, etc, please note here:

If you have ever been diagnosed with cancer, what type was it, where, how long ago, and what stage?

If so, are you in remission?
Yes No
What was your treatment?

Are you undergoing treatment right now?
Yes No

Please check all conditions that may apply as of today:

cold flu allergies candida

lupus scleroderma Myofascial Pain Syndrome fibromyalgia

hives skin burns acne alopecia sunburn
vitiligo rosacea skin cancer boils

halitosis liver issues lead poisoning
tinnitus nasal congestion sinusitis

As above, please check all conditions that may apply as of today:

high blood pressure low blood pressure blood clots
hemophelia arteriosclerosis congestive heart failure
angina stroke

depression epilepsy bi-polar disorder schizophrenia
migraine headache anxiety stress/tension
dizziness insomnia
autism Asperger's syndrome

diabetes ulcers diarrhea
constipation hernia toothache
TMJ Issues swollen glands osteoporosis
tendinitis bursitis

Please take the time to further explain any of the above checked items if you have not already done so on this form:

I have provided all relevant medical information to the best of my recollection. I understand that the Massage Therapist may refer me to a physician based on observation and assessment which is within our Scope of Practice, however no Massage Therapist is qualified to make a diagnosis. I do not have any present injuries or health conditions barring me from receiving Therapeutic Massage, nor have I been advised by a doctor to avoid massage because of any chronic or acute condition.

Please digitally sign by typing your initials in the box below:

(Please click 'Submit' at left to send this information to us.)





Please email, or call 877 480 8038 for more information or to book an appointment.

Cash, PayPal, Credit Cards, and Gift Certificates accepted. Insurance plans accepted: County / Municipal Health Care Plans (NJ), Independent Health Flex Fit, Preferred Care, No-Fault with Authorization

Note: We offer *strictly* therapeutic massage therapy. We do *NOT* offer as€nsual u'massage', in any form.


Red Cross CPR Training For Massage Therapists Web Page NCTMB - National Certification Board for Therapeutic Massage and Bodywork Web Site




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