Raleigh Massage
RALEIGH MASSAGE
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Massage Intake Form
Name
*
Date
*
Evening
Street Address
*
City/ State/ Zip
DOB
Occupation
Employer
Email Address
*
Primary Physician
Emergency Contact
Relationship
Phone
Medical Information
Are you talking any medications?
*
Choose
Yes
No
If yes, please list name and use:
Are you currently Pregnant?
Yes
No
If yes how far along?
Any high risk factors?
Do you suffer from chronic pain?
Yes
No
If yes please explain
What makes it better?
What makes it worse?
Have you had any orthopedis injuries?
Yes
No
If yes please explain
Please indicate any og the following that apply to you.
Cancer
Headaches/ Migraines
Arthritis
Diabetes
Joint Replacement's
High/ Low Blood
Neuropathy
Fibromyalgia
Stroke
Heart Attack
Kidney Dysfunction
Blood Clots
Numbness
Sprains or Strains
Explain any conditions you have marked Above:
Client Signature
Date
*
Massage Information
Have you had a professional massage before?
Yes
No
What type of massage are you seeking?
Relaxation
Therapeutic/ Deep Tissue
Other
Do you have any allergies or sensitivities?
Light
Medium
Deep
Have you had a professional massage before?
Yes
No
Please explain
Are there any areas ( feet, face, abdomen, etc.) you do not want massaged?
Yes
No
Please explain
SOAP Note
Client Name
*
Session Type
Date of Service
Duration
Subjective information provided by client
Objective information and Modalities Applied
Assessment
Plan and recommendations
Therapist Signature
*
Date
*
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