Kevin Harris, LMT - Client Intake Form
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First Name *
Last Name *
Contact Phone Number *
Email address (optional)
Referred by (optional)
Street Address (including city and zip code) *
Date of Birth *
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Emergency Contact Name *
Emergency Contact Relationship *
Emergency Contact Number *
Physician’s Name *
Physician’s Contact Number *
Have you had a professional massage before? *
If yes, date of last treatment
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How would you rate your general health? *
List current medications and conditions they are treating, if any
List any major accidents or surgeries, including dates, if any
Describe any allergies or hypersensitivities, if any
Date of this initial visit *
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Reason for initial visit *
Head and Neck
Check all that apply
Headaches/migraines
Ringing in ears
Vision Problems
Vertigo/dizziness
Hearing loss
Vision loss
Additional information or explanation
Cardiovascular
Check all that apply
High blood pressure
Heart attack
Heart disease
Phlebitis/varicose veins
Hemophilia
Chronic congestive heart failure
Family history of cardiovascular problems
Low blood pressure
Stroke
Poor circulation
Pacemaker
Additional information or explanation
Respiratory
Check all that apply
Asthma
Chronic cough
Emphysema
Frequent colds
Family history of respiratory difficulties
Shortness of breath
Bronchitis
Sinusitis
Smoker
Additional information or explanation
Nervous System
Check all that apply
Sensory loss/change
Sciatica
Seizures
Numbness/tingling
Epilepsy
Multiple sclerosis
Additional information or explanation
Musculoskeletal
Check all that apply
Arthritis
Osteoporosis
Bursitis
Pins/plates/wires/artificial joints
Family History of arthritis
Tendonitis
Jaw pain (TMJ)
Additional information or explanation
Skin and Infections
Check all that apply
Hepatitis
Herpes
Lyme disease
HIV/AIDS
Tuberculosis
Infectious skin conditions
Additional information or explanation
Reproductive System
Check all that apply
Pregnant
Gynecological problems
Given birth
Additional information or explanation
Other Conditions
Check all that apply
Cancer
Digestive conditions
Fibromyalgia
Depression
Psychiatric disorder
Diabetes
Unexplained weight loss
Chronic fatigue syndrome
Anxiety
Other conditions not listed above
COVID-19 Screening (check all that apply) *
Required
Massage Session Music *
It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. Massage therapy is not a substitute for medical examination or diagnosis. It is recommended that I see a physician for any physical ailment that I may have. I understand that the massage therapist does not prescribe medical treatments or pharmaceuticals and does not perform any spinal adjustments. I am aware that if I have any serious medical diagnosis, I must provide a physician’s written consent prior to services. *
I acknowledge that the massage therapist/licensee shall drape the breasts of all female clients and not engage in breast massage of female clients unless the client gives written consent before each session involving breast massage. *
I acknowledge that draping of the genital area and gluteal cleavage will be used at all times during the session for all clients. *
I acknowledge that the massage therapist/licensee must immediately end the massage session if a client initiates any verbal or physical contact that is sexual in nature. *
I understand that if I, the client, am uncomfortable for any reason, I, the client, may ask the massage therapist/licensee to end the massage, and the massage therapist/licensee will end the session. The massage therapist/licensee also has a right to end the session if uncomfortable for any reason. *
I understand that my personal health information will be collected. I understand that all information that I provide will be kept confidential unless required by law. I understand and consent that my medical information may be shared by the various care providers involved in my care and treatment. *
I understand that close contact with people increases the risk of infection from COVID-19. *
By adding my initials below, I acknowledge that I am aware of the risks involved and give consent to receive massage from this practitioner. *
Today’s Date *
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