Full Circle Confidential Client Intake Form

First Name:
Last Name:
Date of Birth:
Billing Address:
Street:
City:
State:
Zip:
Home Number:
Cell Number:
Email Address:
Emergency Contact:
Emergency Contact Phone:
Occupation:

The following areas of the body are typically worked on during massage. Please check any area that you would not like massaged.

Face	Head	Neck	Upper Chest
Arms	Hands	Feet	Legs
Buttocks	Back	Abdomen

MEDICAL HISTORY

Allergies	Headaches	Vision Problems
Sinus Problems	Jaw pain/teeth grinding	Fatigue
Depression	Sleep difficulties	Chronic Pain
Chronic Pain	Numbness/tingling	Sprains/strains
Scoliosis	Arthritis	Tendonitis
Vericose veins	Blood clots	High/low blood pressure
Diabetes	Cancer/tumors	Infectious disease
Skin problems

Women Only:

Pregnant

Painful Menstruation

Endometriosis

Men only:

Prostate Problems

List all medications/herbs/vitamins you are currently taking:


List physical activities you participate in regularly:


What movements or activities are limited?


Please list recent/past injuries/accidents/surgeries:


Please list any allergies you may have:


Have you ever received a professional therapeutic massage before?Yes No

If so, how recently?

How often do you receive massage therapy?

Are you currently receiving massages or other treatments and by whom and why? (acupuncture, physical therapy, chiropractic, naturopathic):

What is your main activity at work?:

On Phone	Sitting	Computer Work
Driving Car	Walking	Other

Pick the description that best represents the amount of stress that you experience on a daily basis:
Choose one No Stress Occasional Stress Constant Stress

What do you do to relieve stress?


What do you want to get out of your session?


By clicking the submit button, I agree to the following statements. I am responsible for all charges for services provided. I understand the benefits and risks of massage and give my consent for massage. I will consult my practitioner with any questions or concerns immediately. I understand that this is a therapeutic massage and any sexual remarks or advance will terminate the session and I will be liable for payment of the scheduled treatment. I have stated all medical conditions that I am aware of and will keep my practitioner informed of any changes. I further agree to communicate to my therapist in the event that there is inadequate or excessive pressure causing pain or discomfort throughout the session. I agree to provide 24 hour cancellation notice or 48 hour cancellation notice during the holiday periods. If I fail to do so, I agree to pay the full appointment fee.