ComplimentYourBody.com
Client Intake Form
Massage Therapy / Personal Training
(Please Print)
Name: _______________________ Date: _________________
Address: ________________________ Apt. #: ________________
State: ________________________ Postal Code: ________________
Home Phone:________________________ Business Phone:________________
Email: ________________________ Date of Birth: ________________
Occupation: ________________________ Referred by: ________________
Current Medications:__________________________________________________
___________________________________________________________________
Previous surgery and date:_____________________________________________
___________________________________________________________________
Dislocations/Broken Bones and date:____________________________________
___________________________________________________________________
Are you currently under a doctors care, and if so, signature below gives ComplimentYourBody.com
permission to contact your primary care physician if necessary before proceeding with treatment.
__________________________________________________________________
Allergies:(oils, cremes, scents, detergents, other): ________________________
__________________________________________________________________
Emergency contact:
Name____________________________________ Phone___________________
Please check any conditions below that affect you:
___ Arthritis ___ Headaches ___ High Blood Pressure
___ Low Blood Pressure ___ Cancer (describe) ___________________
___ Skin Problems ___ Diabetes (describe)___________________
___ Sleep Disturbances ___ Stroke ___ depression
___ Contagious Disease ___ Circulatory Problems ___ thyroid disorder
(hypo/hyper)
___ Smoker (how many per day)________
___ Alcohol (how many per day)________
___ Caffeine (describe) _______________
Please circle any of the following that apply:
scoliosis broken bones spinal problems
spasms/cramps tendonitis/bursitis rheumatoid
arthritis
sprains/strains low back
problems osteoarthritis
osteoporosis neck/shoulder/arm pain sciatica
numbness/tingling dizziness/ringing in ears gas/bloating
irritable bowel syndrome heart condition
Describe any conditions circled above:________________________________
___________________________________________________________________
___________________________________________________________________
Female clients only:
Are you pregnant? If so...due date? _________________________________
How would you describe your cycles?_______________________________
Lifestyle:
Do you currently exercise or have you in the past? (describe)_________________________________________________________________
_________________________________________________________________
How would you describe your eating habits:
_________________________________________________________________
_________________________________________________________________
Personal training clients only:
What are your goals for training?______________________________________
How many hours a week will you commit to obtaining your goals?___________
Consent for care:
I have been cleared by my physician to receive massage therapy and/or personal
training. I give my consent to receive such treatment and have reported all present health conditions. I will inform practitioner of
any future changes in my health condition. I will also inform practitioner if at any point I feel pain or discomfort and the
session will be modified to accommodate. All information provided above will be kept confidential.
Signature: _______________________________________ Date: ___________
Signature parent/guardian: ________________________ Date: ___________
