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.

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.

Eczema Open wounds or sores Rashes or undiagnosed skin condition Acne Fungal infection (e.g. ringworm, athlete's foot) Contagious skin condition

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)

Lifestyle and treatment preferences

Reason for seeking massage therapy today Areas you would like focused on Areas you would like avoided Preferred pressure 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.