Click on this link to download and fill out your intake form. Have it ready to go ahead of time so we can get you started and on your way to feeling better!
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Client Intake Form
Name_____________________________________ Phone#_______________ DOB________ Today’s Date____________ Address_____________________________________________________ Email___________________________________ Emergency contact Info._______________________________________ Occupation___________________________ Insurance Carrier___________________________ Primary Physician Info.___________________________________
Have you ever had a professional massage? _________________ When was your last treatment? _____________________
Any other treatments received? Acupuncture – Chiropractic – Physical Therapy – Naturopathy – Other_______________
_______________________________________________________________________________________________________________
Please mark any conditions below you have ever experienced or are currently experiencing.
- Allergies – Types ____________________________________________________________
- Frequently Suffer from Stress
- Broken Bones – Specify ____________________________________________________________
- Injuries causing Chronic problems – Specify ____________________________________________________________
- Bruise Easily/Sensitive to Touch or Pressure
- Diabetes
- Frequent Headaches – Specify ____________________________________________________________
- High or Low Blood Pressure
- Taking Medications for Blood Pressure
- Joint Swelling
- Trouble Sleeping
- Epilepsy or Seizures
- Cancer - Cancer Treatments – Specify ____________________________________________________________
- Any Other Medical Conditions or Medications – Specify ___________________________________________________
- Any Supplements You're Currently Taking - Specify_________________________________________________________
- Tension or Soreness in a Specific Area – Specify _________________________________________________________________
- Pregnant
- Varicose Veins – Deep Vein Thrombosis
- Any Contagious Diseases – Specify _________________________________________________________________
- Osteoporosis
- Arthritis
- Rheumatoid Arthritis
- Cardiac or Circulatory problems
- Back Pain
- Neck Pain
- Shoulder Pain
- Bone and/or Joint Degeneration
- Fybromyalgia
- Numbness, Tingling, or Stabbing Pains – Specify ________________________________________________________________
- Any Surgeries – Specify ________________________________________________________________
- Edema
- Depression
- Fatigue
- Digestive Problems
Please read carefully the following disclaimer and sign where indicated.
Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated, to the best of my knowledge, all my known medical conditions/history and answered all questions honestly. I understand that if I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the appropriate adjustment can be made for my comfort. I further understand that bodywork should not be construed as a substitute for medical examination or diagnosis, and that I should see a physician, chiropractor, or other qualified medial specialist for any mental or physical ailment of which I am aware. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the part of the practitioner, or the establishment of Taylor Made Energetics, should I fail to do so.
Client signature_____________________________________________________________ Today’s date____________
Consent to Treatment of a Minor: By my signature below, I hereby authorize All Wellness Practitioners within Taylor Made Energetics to administer Bodywork, Massage, Energy Healing or other therapy techniques to my child or dependent as they deem necessary. I understand that the practitioner will keep me informed of any problems and/or improvements as they deem necessary, for said minor may need assistance and reassurance from me.
Client Signature_____________________________________________________________ Today’s Date____________