Cloud9 Massage Client Intake Form

Cloud 9 Massage Client Intake Form

In this form are the details of your massage session with MASSAGE CLOUD9. Please take a moment to carefully answer the following questions. If you have a specific medical condition or specific symptoms, massage/bodywork may be contraindicated. A referral from your primary care provider may be required prior to service being provided.
Submit Date
Client Full Name

First NameLast Name
Phone (to receive appointment reminder)*

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email address (to receive appointment reminder)*
Occupation
How do you know about us?
Referred by
MASSAGE INFORMATION
Have you had a professional massage before?

YesNo
If yes, do you have a style or pressure preference? (WE NO LONGER PROVIDE DEEP/FIRM PRESSURE)

Light pressureBetween light and moderate pressureModerate pressure
Are you sensitive to fragrances or perfumes?

YesNo
Do you have sensitive skin?

YesNo
Are you a highly sensitive person in general?

YesNo
Circle any specific areas you would like the massage therapist to concentrate on during the session.
MEDICAL HISTORY
Do you suffer from chronic or persistent pain/discomfort?

YesNo
If Yes, for how long
Choose which apply

Headaches / MigrainesCancer / TumorsTypeAllergies / SensitivityAbnormal skin conditionArthritis / TendonitisHeart / Circulation problemsJoint replacement / SurgeryHigh/Low blood pressureMajor accidentVaricose veinsBlood clotsNeck / Back InjuriesDiabetesParalysisFibromyalgiaNumbnessSprains, StrainsRecent injuriesLack of or reduced feeling/SensationNeuropathyInflammatory skin conditionsAutoimmune condition (MS, Lupus, RA, etc.) Open wounds or soresPeripheral vascular diseaseCompromised immune systemEdema or LymphedemaThrombosisImplantable medical device e.g pacemakerOther
Explain any condition you have marked above:
Are you currently taking any prescription medication? If so, for what?
For PREGNANCY client only

High-risk pregnancyPreeclampsiaPregnancy-induced hypertension (PIH)Previous pre-term laborVaginal bleedingAbdominal painDiarrheaSudden severe headachesSevere swellingSevere high blood pressureOther
For PREGNANCY client only :Explain any condition you have marked above:
For PREGNANCY client only: Are you currently taking any prescription medication? If so, for what?
Patient Consent for Treatment

Please read and sign below.

I realize that I, the client, am responsible for keeping my massage therapist informed of any condition or health issue that may affect this bodywork session. The information shared on this form and during each session is kept confidential between the therapist and myself. I, the client, understand that massage is a form of health and wellness maintenance, which may facilitate various types of healing, however, is not intended to replace medical treatment if otherwise necessary. Any suggestions made by the massage therapist in relation to any health issues are recommendations and not prescriptions.

MassageCloud9 does not handle insurance claims; however we are glad to give you a receipt for your keeping. If any copies of records are requested, an administrative fee will be charged.

A gentle reminder: Please call 24 hours prior to scheduled appointment to avoid paying the full fee of the scheduled session. (First time emergencies and illness will be taken into consideration). The full fee must also be paid for not showing up at all. Please arrive on time for your session to receive the full benefit.

MassageCloud9 provides non-sexual massage. The therapist can terminate the session at any given time if direct or indirect suggestions are made that place the therapist in an uneasy situation. Full payment will be expected.
Client Signature

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Should be Empty:

Cloud 9 Massage Client Intake Form