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New Client Intake Form

(click here to download Microsoft Word version of this form to fill out then e-mail or bring to appointment) 

Howard Northrup, LMT   

New Client Confidential Health Intake Form
 MA# 35627

 

At your first appointment, I will need the following information.

Please enter all information and submit to me, Howard Northrup, LMT. 

 

(Note: This web page is not Secure, so your information could possibly be intercepted over the web. If you do not feel comfortable sending your information on this form over the web, please print the form, fill it out, and hand it to Howard.) 

 

Hint: Use your Tab key to move from one field to the next--if you press the Enter key, that will submit the form.

 

 Name   

 Street Address   City State Zip

 Home Phone         Cell phone

 e-mail address     Birth date   

Medical History and Information

    Certain medical conditions may be contraindicated for massage or may need physician’s approval.

    Please check all that currently apply or have applied in the past 5 years:

  Stress   TMJ Dysfunction (jaw)   Pinched Nerves   Loss of Smell
  Anxiety   Chronic Fatigue Syndrome   Muscle Spasms   Loss of Taste
  Insomnia   Diabetes   Shoulder Tight   Ulcers
  Depression   Tuberculosis   Shooting Neck Pain   Indigestion
  Fibromyalgia   Kidney Trouble   Dizziness   Intestinal Gas
  Migraines   Liver Function Problem   Loss of Balance   Constipation
  Headaches   Sudden Muscle Pain   Bulging Disk   Hay Fever
  Heart Attack   High Blood Pressure   Herniated Disk   Sinus Trouble
  Chest Pain   Low Blood Pressure   Swollen Joints   Anemia
  Cancer   Pacemaker   Swollen Ankles   Cold Sweats
  Pregnant   Numbness   Nervousness   Face Flushed
  Stroke   Tingling   Cold Hands or Feet   Other (specify):
  Asthma   Varicose Veins   Ringing in Ears   Other (specify):

 Have you ever had a massage?   When was your last massage?

 List major injuries/surgeries/conditions within last 5 years:

 

 List all prescriptions/herbs/vitamins currently taking:

 

What are your main activities every day? (check all that apply)   On phone     Sitting     On Computer

 Driving       Walking     Other (please specify): 

What movements or activities (if any) are limited?

What other treatments are you currently receiving (physician, acupuncture, physical therapy, chiropractic, herbalist, naturopathic):  

I am responsible for all charges for all services provided.  I understand the benefits and risks of massage and give my  consent for massage.  I will consult my practitioner with any questions or concerns immediately.  I have stated all medical  conditions that I am aware of and will keep my practitioner informed of any changes. I understand that massage treatments are not substitutes for treatments by a qualified medical specialist. If I experience any discomfort during the massage, I will inform the therapist immediately. I understand that any illicit or sexually suggestive remarks or advances will result in the immediate termination of the session. By entering my initials below, it indicates my agreement and understanding of the above statements:

 Initials (max. 3 characters):           Today's Date: