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Client Intake Form

Please fill out the following form to help us understand your physical condition.

First Name

Email Address

Last Name

Date of Birth

Mobile Phone

Work Phone

Home Phone

Referred by

Address

State

City

Zip

Emergency Contact

Emergency Contact Relationship

Emergency Contact's Number

Physician's Name

Physician's Number

How would you rate your general health? *

Excellent

Good

Fair

Poor

Are you currently suffering from a medical condition, illness, or injury? *

Yes

No

If you answered yes, please elaborate

List current medications & the conditions they are treating.

List any major accidents or surgeries (including dates).

Please tell us about any allergies or hypersensitivities.

Reason for your initial visit

Have you had a professional massage?

Yes

No

If yes, date of last treatment.

For the conditions listed below, please check all that apply.

HEAD & NECK

Headaches / migranes

Ringing in ears

Vision problems

Vertigo/dizziness

Hearing loss

Vision loss

RESPIRATORY

Asthma

Shortness of breath

Chronic cough

Bronchitis

Emphysema

Sinusitis

Frequent colds

Smoker

Family history of respiratory difficulties

NERVOUS SYSTEM

Sensory loss / change

Numbness / tingling

Sciatica

Epilepsy

Seizures

Multiple sclerosis

REPRODUCTIVE

Pregnant

Given birth

Gynecological problems

CARDIOVASCULAR

High blood pressure

Low blood pressure

Heart attack

Stroke

Heart disease

Poor circulation

Phlebitis / varicose veins

Pacemaker

Hemophilia

Chronic congestive heart failure

Family history of cardiovascular problems

SKIN & INFECTIONS

Hepatitis

HIV / AIDS

Herpes

Tuberculosis

Lime disease

Infectious skin conditions

MUSCULOSKELETAL SYSTEM

Arthritis

Family history of arthritis

Osteoporosis

Tendonitis

Bursitis

Jaw pain (TMJ)

Pins / plates / wires / artificial joints

OTHER CONDITIONS

Cancer

Diabetes

Unexplained weight loss

Digestive conditions

Fibromyalgia

Chronic fatigue syndrome

Depression

Anxiety

Psychiatric disorder

Other conditions not listed

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. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status.

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.

Treatments may be covered by extended health care plans. I understand that it is my responsibility to confirm the exact details of my coverage.

Initials

Today's Date

Your Signature

I declare that the info I’ve provided is accurate & complete

Thank you for submitting your Intake Form!

After hitting "Submit" the form will clear.

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Info

Tel: 818-309-3379

Email: info@galeneeffleurage.com

Deborah Guzman (Owner)

Certification #86926

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