Massage Client On-Line Intake Form

Janet Jordan Therapeutic Massage Client Information Form

Instructions
Print this form. Fill out all applicable information and
call Janet at 268-9443 to set an appointment. You may also mail your form to
7611 Indian School NE Suite 104 • Albuquerque, NM 87110

Name _____________________________________________ Address ___________________________________________ City ________________________ ST _____ Zip ___________ Occupation _________________________________________		Birth Date _______________________ Telephone # _____________________ Business # ______________________ SSN ___________________________

How did you learn about me? ___________________________ Your Insurance Company (if applies) _____________________ Address ___________________________________________ City ________________________ ST _____ Zip ___________		Telephone # _____________________ Adjustor ________________________ Telephone # _____________________ Claim # _________________________

Have you received Massage Therapy or Bodywork before? _________ What Kinds? ____________ How often? ___________________________________________________________________

Please check off any of the following conditions or symptoms which apply to you now or in the past:
____ High Blood Pressure ____ Contact Lens ____ Low Back Pain ____ Allergy to Nut Oils ____ Osteoporosis ____ Diabetes ____ Pregnant	____ Blood Clots ____ Low Blood Pressure ____ Varicose Veins ____ Bursitis ____ Skin Infections ____ Hypo or Hyperglycemia ____ Contagious Conditions		____ Muscle Sprain / Strain ____ Heart Attack / Stroke ____ Arthritis ____ Headaches ____ Other Conditions

Please list and explain other conditions/symptoms you are or have experienced: __________ ___________________________________________________________________________________

Have you had any serious or chronic illness, operations, or traumatic accidents? _______ If yes, please explain: ___________________________________________________________ ____________________________________________________________________________________

Are you currently, or have you at any time within the last 12 months been under the care of a physician? If so, for what condition?________________________________________________ ____________________________________________________________________________________

Are you on any medication? _______ If yes, which ones? ________________________________ May I have permission to contact your Doctor / Therapist? ________
Doctor / Therapist Name: ______________________________ Telephone __________________

Do you exercise? _____ How many times per week? _____ For how long? __________________

What percentages of the foods you eat would you say are:

Grains _______	Fruits ______	Meats ______	Fish ______	Dairy ______
Vegetables ______	Desserts/Sugar ____	Junk Foods ____

How many ounces of water do you drink per day? ___________________________



Do you drink caffeinated beverages? _______ If so, how many bottles/cups per day of the following? Soda Pop______ Coffee________ Black Teas_________


Do you smoke cigarettes? _________	How many per day? __________
Do you consume alcohol? _________	How many drinks per: Day _____ Week _____

I have completed this health form to the best of my knowledge. I understand that Massage Therapy and Bodywork services are a therapeutic health aid and are non-sexual. They do not take the place of a physician's care when indicated. Any information exchanged during a Massage or Bodywork session is confidential and is only used to provide you with the best health care services.

If I am not able to make a scheduled appointment, I agree to cancel the appointment 24 hours in advance by phone, unless I have an emergency. In this case, I will call ASAP to reschedule my appointment.

If I miss a scheduled appointment without giving 24 hr. notice, I agree pay any missed appointment charge applicable.

I am responsible to pay for any Massage or Bodywork fees not paid for by my insurance company.

Name (signature) _________________________________________ Date _____________________