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HEALING MOTIONS
LLC

S E R V I C E S
P H I L O S O P H Y
C O N T A C T
BOOKING & PRICES
MASSAGE BENEFITS
CLIENT INTAKE FORM Massage
CLIENT INTAKE FORM Lymphatic
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Client intake form

Hello! Please complete a client intake form before your service. We will need this on file for every person who books with Healing Motions LLC. Thank you! We look forward to helping you on your healing journey!

Client Intake form:

Client information:

First name*

Last name*

Phone (select country first)*

Email*

Gender*

Male

Female

Birthday*

Month

Day

Year

Occupation

Physical Address

Multi-line address

Country/Region*

Address*

City*

Zip / Postal code*

Service Location Address

Check if the same as Physical Address

Multi-line address

Country/Region

Address

City

Zip / Postal code

Company name

Health Information:

Please select all that apply:*

Headaches

Neck Pain

Seizures

Back Pain

Leg/Knee pain

Jaw Clenching/ Grinding

High Blood Pressure

Bruise easily

Varicose Veins

Diabetes

Numbing/ Tingling

Blood Clots

Cancer

Autoimmune Disorder

Heart Condition

Stroke

Tendonitis

Bursitis

Sciatica

Osteoporosis

None

Other

Any Medical History not listed?

Are you currently under medical supervision or the care of a physician? *

Yes

No

If yes, please explain:

Do you need Physical assistance getting on or off the massage table?*

Yes

No

If You need Physical assistance you must have someone available to assist you at the time of the appointment.

Are you currently taking any medications?*

Yes

No

If yes, Please list any medications.

Do you have any allergies?*

Yes

No

If yes, please explain:

Are you pregnant?*

Yes

No

If yes, how far along?

Areas of broken skin? (e.g. rash, wounds)*

Yes

No

If Yes, Where?

Any Injuries or medical procedures in the last 3 years?*

Yes

No

If yes, describe:

Describe any other injuries or health conditions:

Massage Information

Have you had a Massage before?*

Yes

No

Reason for seeking massage*

Relaxation

Specific problem

If you have a specific problem, please elaborate.

How much pressure do you prefer?*

Light

Medium

Firm

I understand That massage therapy is provided for stress reduction, relaxation, relief from muscular tension, and improvement of Circulation & energy flow.

If I experience pain or discomfort during the session, I will immediately inform my therapist so that pressure/ strokes can be adjusted to my level of comfort. I will not hold my therapist responsible for any pain or discomfort I experience during or after the session.

I understand that services provided are not suitable for medical care and that my therapist is not qualified to diagnose, prescribe, or treat physical/ mental illness.

I affirm that I have notified my therapist of all known medical conditions.

I agree to inform the therapist on any changes in my health and medical condition and that there should be no liability on the therapists part should I forget to do so.

I understand that massage is entirely theraputic and non- sexual in nature.

By signing this release, I waive and release my therapist from any liability, past, present, and future, relating to massage therapy and bodywork.

Signature*

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