Client Bodywork Intake Form

First name

Last name

Phone

Address

Please add any gate or parking instructions necessary for in-home services

Birthday

Month

Day

Year

How did you find me?

Do you have experience with professional bodywork or massage?

Anything else?

Do you have goals for our work together?

Are there any areas of the body you wish to focus on?

yes

If yes, please list any areas you wish to spend focused time on

Please list any areas you do not wish to have touched. If none please type N/A

Anything you are managing or under the care of a health professional for -physically or mentally ?

How does your body typically move through a week?

What kind of movements are most common for you? sitting, walking, reaching, lifting, running, resting, exercising

What activities do you do for exercise?

Please share any acute or chronic injuries or areas of concern you may have that are additional to your areas of focus.

Please list medications you are taking.

Please list any allergies you have. (including to lotions, oils, scents, or adhesives)

How would you rate your current stress level?

When you're stressed or under pressure, where do you typically feel it first?

On a normal day, how much do you notice what's happening in your body?

I don't usually notice my body or think about it at all

I notice when something hurts

I'm aware of it much of the time

I'm very tuned into my body and how I feel in any given moment

Is there anything about being touched that is complicated for you?

You don't need to explain if you would rather talk in person. Just letting me know something is there is enough and we can discuss it before our session.

If something isn't working for you during a session, how do you usually let someone know?

Is there anything else you would like me to know before we work together?

Please share 4 words that describe how you would like to feel at the end of our session.

Consent & Agreement

I understand that massage therapy is intended to promote relaxation, relieve muscle tension, and improve circulation. I acknowledge that Kinconnxon does not diagnose illness, disease, or any physical or mental disorder, nor do they prescribe medical treatment or pharmaceuticals.
I understand massage and bodywork is not a substitute for medical care.
I affirm that I have stated all known medical conditions and answered all questions honestly.
I agree to keep the therapist updated as to any changes in my health profile and understand that there shall be no liability on the therapist's part should I fail to do so.
I give consent for Kinconnxon to work within their scope of practice and comfort level based on the information I provide.
By checking the box I agree that I have read and understand all parts of this Intake, Agreement and Consent Form.
By signing below, I give my informed consent to receive massage therapy. I understand I may withdraw consent or stop treatment at any time.

I agree to the terms and conditions.

Yes! I want to receive your newsletter including events, updates, research and wellness tips. (please uncheck this box if not.)

Signature

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