Client Medical Intake Form

This consultation is an important part of your treatment. The information gathered here helps your therapist plan a session that is safe and appropriate for you.

All information is collected to protect both you and your therapist. Please answer as honestly and fully as possible. Your responses are held in strict confidence.

Returning client? If you've booked with us before and already submitted a medical intake form, you don't need to submit it again, unless your medical situation, contact details, emergency contact details or address have changed.

Personal details

First name

Last name

Date of birth

Phone number

Email address Address Emergency contact name and number

Medical history

Tick any conditions that apply to you, past or present.

Details of any conditions ticked above, including dates and current status Current medications (including supplements and herbal remedies) GP name and contact details

Skin conditions

Please disclose any skin conditions. This information is used to prevent cross-contamination and infection and to ensure your treatment is safe.

Bacterial infections

Viral infections

Herpes simplex (cold sores) Herpes zoster (shingles) Verrucae or warts

Infestations

Scabies Head lice Body or pubic lice

Fungal conditions

Athlete's foot (Tinea pedis) Ringworm of the skin Ringworm of the nails

Sebaceous conditions

Other skin conditions

Eczema Open wounds or sores Rashes or undiagnosed skin condition Sunburn Contagious skin condition (other)

Blood-borne conditions — disclosed in confidence. Used solely to ensure safe practice.

Hepatitis A Hepatitis B Hepatitis C HIV or AIDS

Psoriasis

None Mild Moderate Severe

Details of any skin conditions noted above, including affected areas Do you have any bruising at present?

No Yes

If yes, please describe where on the body Known allergies (including latex, oils, nut-based products)

Session preferences

During your session, would you prefer

Music To talk Silence No preference

Body type

This helps your therapist set up the right treatment couch for you, one with the correct width and a weight capacity suited to you, so it's stable and comfortable throughout your session. Please select whichever description fits best.

Ectomorph — a naturally slim, narrow build with long limbs Mesomorph — a medium, naturally muscular or athletic build Endomorph — a broader, softer build that carries more weight Combination, or not sure

Would you like the treatment couch heated or unheated?

Heated Unheated No preference

Line of work, if applicable

Many jobs place repeated strain on particular areas of the body. Knowing your line of work helps your therapist anticipate where tension is likely to be held.

If other, or you'd like to add detail about your work Areas you would like focused on Areas you would like avoided, or given less attention Preferred pressure

Light Medium Heavy No preference

Additional information

Reason for seeking massage therapy today Have you had professional massage before?

Yes No

If yes, any reactions or concerns from previous treatments? Do you use recreational drugs or drink alcohol regularly?

Yes No

Anything else your therapist should know before your session

Consent and declaration

Full name (in place of signature)

Date

Thank you. Your form has been received.