Deep Tissue Thai Client Intake Form
New Clients please complete this intake form before your first appointment.
Name *
Street Address *
City *
Zip Code *
Phone Number *
Email *
Age *
Date of Birth *
MM
/
DD
/
YYYY
Sex *
Emergency Contact (Name & Phone #) *
What is your primary health concern? *
Are you presently under the care of a medical doctor or health practitioner? *
Are you on any form of medication? *
Do you have any restriction in movement? *
Are there any stretches or yoga postures that may be harmful? *
What type of exercise do you practice on a regular basis?
 *
Are you pregnant? *
Due date
MM
/
DD
/
YYYY
Do you have or wear:
Are you currently on your cycle?
Clear selection
Please indicate any conditions you have:
Have you had a professional massage before? *
If yes, how often do you receive massage therapy?
Do you have any difficulty lying on your front, back or side? *
If yes, please explain:
Do you have any allergies to oils, lotions, or ointments? *
If yes, please explain:
Do you have sensitive skin? *
Are you wearing:
Do you sit for long hours at a workstation, computer, or driving? *
Do you perform any repetitive movement in your work, sports, or hobby? *
If yes, please describe:
What is your occupation?
Using the chart above, indicate numbered areas of your body where you are experiencing pain. If "other," please describe.
Have you had a recent major surgical procedure or injury? *
If yes, please explain:
Are you currently seeing a Chiropractor, Physical Therapist, or Physician for an ongoing issue? *
If yes, please explain:
Please indicate your stress level: *
Low
High
What do you hope to have addressed by visiting a Thai Massage practitioner? *
How did you hear about Deep Tissue Thai? *
Consent for Thai Massage
It is understood that the purpose of Deep Tissue Thai Massage is for relaxation and that it is not meant to diagnose or treat any illness, disease, or any other physical or mental disorder, injury, or condition. I have informed Matthew Wakem about my state of health and I have transmitted any recommendations and restrictions on the part of my medical doctor or therapist insofar as massage is concerned. I understand that if I become uncomfortable for any reason that I may ask Matthew to end the massage session, and he will end the session. Client agrees to immediately inform Matthew of any unusual sensation or discomfort so that the application of pressure may be adjusted to Client’s level of comfort. I am aware that Deep Tissue Thai bodywork can be deep and painful at times and that I am here voluntarily.

Client hereby assumes fully responsibility for receipt of the massage therapy, and releases and discharges Matthew Wakem from any and all claims, liabilities, damages, actions, or causes of action arising from the therapy received hereunder, including, without limitation, any damages arising from acts of active or passive negligence on the part of the Therapist, to the fullest extent allowed by law. Client, in signing this consent for Therapy and Waiver of Liability (“Consent”), understands and agrees that this Consent will apply to and govern the current and all future therapy sessions performed by Matthew Wakem.
Type your full name to indicate consent *
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