Intake Form

Please complete the bodywork intake form prior to your session

Name

First Name

Last Name

Date

YYYY

Home Phone

(###)

###

####

Mobile Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Occupation

Have you received massage therapy/MFR or yoga before?

Yes

How often?

Reason for receiving massage therapy/MFR/yoga and areas focus for your session

Are there any activities that aggravate your current condition?

Are you currently under a physician's care?

Yes

If so, for what?

Please list any surgeries, accidents, or injuries in the last five years, including dates

Please list any medication you are currently taking, including over the counter drugs and herbal remedies

I understand that the message therapy provided by Rebecca Rizzuto, CMT, CHHC, is for the purpose of stress reduction, pain reduction, relief from muscle tension, increasing circulation, or specific reason notes here

I understand that massage therapy does not diagnose illness or disease, or any other disorder, and that the massage therapist does not prescribe medical treatment or pharmaceuticals, nor are spinal manipulations part of massage therapy

I understand that massage therapy is not a substitute for medical examinations or medical care, and that it is recommended that I am concurrently working with my primary caregiver for any condition I may have

I have stated all my known physical conditions, medical conditions, and medications, and I will keep the massage therapist updated on any changes

I understand that all cancellations must be made at least 48 hours in advance; otherwise, payment in full is required

Client Signature

Date

YYYY