Client Intake form for Joel Rayburn LMT

Please fill out the Client Intake form below for Joel Rayburn, LMT
First Name
Last Name
Address
City
State
Zip	format xxxxx or xxxx-xxxx
Contact Phone	Format:xxx-xxx-xxxx
Email Address
Height	Inches
Weight	Lbs
Date Of Birth
Profession
Referred by
Physician Name
Physician Phone

Current Health
Do you exercise regularly and/or participate in any sports?
If yes, which sports?
Have you recently suffered an injury?
If yes, describe:
Have you had any areas of inflammation?
If yes, describe:
Are you currently under the care of a physician?
If yes, explain:
Have you had recent surgery?
If yes, explain:
Medications Allergies:
Massage Experience
Have you had a professional massage before?
What types of massage/bodywork have you had:
How long have you been receiving massage therapy?
Frequency of treatments?
What are your goals for treatment?:

Health History
Contact lenses?
If yes, explain:
High blood pressure?
If yes, explain:
Low blood pressure?
If yes, explain:
Dentures?
If yes, explain:
Back pain/Sciatica?
If yes, explain:
Ulcer?
If yes, explain:
Spinal problems?
If yes, explain:
Tendonitis, bursitis, etc?
If yes, explain:
Osteoporosis?
If yes, explain:
Arthritis or joint disease?
If yes, explain:
Broken bones?
If yes, explain:
Diabetes?
If yes, explain:
Easy bruising?
If yes, explain:
Seizures/Convulsions?
If yes, explain:
Skin problems?
If yes, explain:
Multiple Sclerosis?
If yes, explain:
Allergies?
If yes, explain:
Nerve degeneration?
If yes, explain:
Varicose veins?
If yes, explain:
Cancer or tumors?
If yes, explain:
Phlebitis/Blood clots?
If yes, explain:
Infectious diseases?
If yes, explain:
Heart problems?
If yes, explain:
Any other medical condition(s) the therapist should be aware of?
If yes, explain:

Please indicate any painful areas on your body?
If you're having a hard time explaining any painful areas, you can use this link to print Body Chart and bring it with you View Body Chart