Massage for Body & Feet
…cuz you are worth it!
Health Intake Form
509-929-3636
Name _____________________________________
Home Phone ________________________
Address: ___________________________________
Cell/Work Phone _____________________
E-mail: ____________________________________
DOB/Age ___________________________
Emergency Contact __________________________
Telephone __________________________
Your Daily Health
Occupation/Daily Physical Activities: ______________________________________________________
Your general diet:______________________________________________________________________
How well do you sleep __________________________________________________________________
Describe your general health: _____________________________________________________________
Your Health History
Please list any major illnesses, broken bones, surgeries, hospitalization, or accidents and dates.
_________________________________________________________________________________
_________________________________________________________________________________
Do you consider that you have recovered from these events? ________________________________
Your Current Health
Do you have any chronic, ongoing conditions that you deal with? Explain.
_________________________________________________________________________________
Are you currently seeing a doctor/chiropractor/other care provider? Explain.
_________________________________________________________________________________
Do you have any skin rashes or other skin problems right now?
_________________________________________________________________________________
Are you taking any medications? Explain.
How did you hear about Massage for Body & Feet Reflexology?______________________________
YOUR GOAL:
Why are you here today? What do you hope to accomplish?
_____________________________________________________________________________________
Intake for Massage For Body & Feet
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Your Health Interests & Concerns
What health concerns do you have for yourself, whether clinically diagnosed or not?
Skin
Digestive
Circulatory
Respiratory
Boils
GERD (reflux)
Anemia
Asthma
Fungal infections
Ulcers
Thrombophlebitis
Emphysema
Herpes simplex
Crohn disease
Embolism
Sinusitis
Warts
Ulcerative colitis
Deep vein thrombosis
Tuberculosis
Eczema
Irritable bowel syndrome
High blood pressure
Allergies/hay fever
Psoriasis
Gallstones
Heart disease
List Other Allergies:
Skin cancer
Cirrhosis
Varicose veins
_________________
Hepatitis
Clotting disorders
Musculoskeletal
Lymph/Immune
Endocrine
Spinal/ Skeletal
Fibromyalgia
Edema
Diabetes
Sciatica
Rheumatoid arthritis
Leukemia/lymphoma
Hypothyroidism
Neck Injury
Osteoarthritis
HIV/AIDS
Hyperthyroidism
Spinal injury
TMJ dysfunction
Chronic Fatigue Syndrome
Urinary
Osteoporosis
Strains, sprains
Lupus
Kidney stones
Joint Disorder
Bursitis/Tendinitis
Other Autoimmune
Kidney ailments
Lumbago
Carpal tunnel
Disorders
Renal failure
syndrome
Bladder ailments
TOS
Nervous
Reproductive
Dependence
Other
Depression
Breast cancer
Alcohol dependence
Migraines
Multiple sclerosis
Endometriosis
Drug dependence
Constipation
Postpolio syndrome
Ovarian cysts
Caffeine dependence
Chronic pain
Headaches
Prostate cancer
Sleep disorders
Stroke
Menstrual Issues
_________________
Seizure disorders
Are you pregnant? Y N
_______________________
Reduced sensation
Are you trying? Y….N
Method of payment today: Cash
Check
Gift Cert.
Insurance (See attached page)
Standard Insurance Policy: “All maintenance and wellness care massages are the financial responsibility of the patient.” This means I cannot bill insurance for maintenance or wellness care massages.
Consent for Treatment & Release of Information per HIPAA 5010
It is my choice to receive massage therapy, reflexology and/or bionic hydrotherapy, and I give my consent to
receive treatment. I understand that I am receiving this treatment at my own risk. I have reported all health
conditions that I am aware of and will inform my practitioner of any changes in my health. I also acknowledge
that I have read and understand the Policies of Massage for Body & Feet, and agree to adhere to them.
My signature below authorizes the release of my records including history forms, chart notes, reports and
billing statements to my healthcare provider, attorney and/or insurance company. I authorize my manual
therapist to consult with any of the above regarding my health and treatment, to provide a more complete
health care plan for myself. Please initial and date here if you deny this option ________________________
____________________________
Signature of Client
_______________________________
Name of Client (Printed)
Intake for Massage For Body & Feet
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____/____/____
Date Signed
MASSAGE & YOU – Complete if you are receiving massage.
Have you ever received a professional massage?
Y
N
How often do you get a massage? ____________ When was last massage? _____________
Circle any part of your body where you prefer to NOT be touched today:
Head
Shoulders Arms
Pectorals Bottom/Rear End
Neck
Abdomen
Hand
Legs
Feet
Please indicate where you have pain:
What do you specifically like in a
massage?
What do you specifically dislike in a
massage?
Do you have any questions about massage?
Yes
No
REFLEXOLOGY & YOU - Complete if you are receiving reflexology.
Circle any that apply today: Fever Infection
Do you have foot problems? Y
N
Circle:
Plantar fasciitis
Neuroma
Plantar warts
Athlete’s foot
Have you ever received reflexology? Y
Cold/Flu
Inflammation
Bone Spur
Bunion
Gout
____________________
N
BIONIC HYDROTHERAPY & YOU - Complete for the Bionic HydroTherapy.
Check the box(es) below if any of the following conditions/symptoms apply to you:
 I am pregnant or lactating (just to be on the safe side).
 I am wearing a pacemaker or on heart beat regulating medication.
 I have had an organ transplant and am on immunosuppressant medication.
 I am on medication, the absence of which would mentally or physically incapacitate me.
 I have an open wound, cut or rash on my lower leg, ankle or foot
If you have any of these symptoms and/or conditions, it is strongly recommended that you consult
your primary physician before using Bionic HydroTherapy.
Intake for Massage For Body & Feet
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