Peaceful Harbor Massage Therapy Client Intake Form
Name_________________________________________
Address_______________________________________
_____________________________________________
City/Town_____________________________________
State_________Zip___________
Phone numbers: Day__________________
Evening___________________
Mobile____________________
OK to leave message? yes___ no___ (Underline preferred
contact number)
e-mail__________________________________________
Would you like to receive our e-mail newsletter and
periodic special offers? yes___ no___
Date of Birth_____________________ Occupation_______________________________________
Current Health____________________________________
Surgery/Serious Illness/Injury history
_______________________________________________
Do you have any of the following?: (check all applicable)
____headaches, migraines
____allergies (nuts, latex, etc.)
____current pregnancy
____vision problems
____contact lenses
____hearing problems
____injuries to face or head
____recent bruises or cuts
____recent dental work or braces
____jaw pain, TMJ
____constipation, diarrhea
____hernia
____abdominal or digestive problems
____chronic pain
____muscle or joint pain
____numbness or tingling
____sprains, strains
____arthritis, tendonitis
____cancer, tumors
____spinal column disorders
____diabetes
____high or low blood pressure
____fatigue
____tension, stress
____depression
____sleep difficulties
____rashes, athlete's foot
____cold, flu, other infectious diseases
____heart, circulatory problems
____blood clots
____varicose veins
____other
Explain any areas noted above_________________________
_______________________________________________
Current medications (including over-the-counter
medications/supplements)
________________________________________________
Are you currently under medical care? yes____ no____
or chiropractic care? yes____ no____
Name of practitioner_______________________
OK to contact? yes____ no____ phone_______________
Have you had massage therapy before? yes____ no____
When/how often?____________________________________
Any particular areas of discomfort/tightness/pain?________________________________________________
Is there someone who we should thank for the referral?__________
________________________________________________
I understand that the massage therapy that I am given is strictly
therapeutic, for the purpose of stress reduction, relief from muscular
tension, and/or improving circulation. I understand that a massage
therapist neither diagnoses illness, disease, or any other medical,
physical, or mental disorders nor performs any spinal manipulations.
I am responsible for consulting a qualified physician for any
physical ailment I may have.
Client signature_________________________________
Date_____________________
Peaceful Harbor Massage Therapy Amherst, NH 603-261-7141
"helping you find the peaceful harbor within"