New Client Intake

Date

Month

Day

Year

First name

Last name

Pronouns:

Birthday

Month

Day

Year

Gender

Woman

Man

Prefer not to say

Prefer to Self-Describe

Phone

Address

Email

Occupation:

Emergency Contact Name:

Emergency Contact Phone:

Are You Pregnant?

Yes

No

Not Applicable

*Pregnancy Disclosure:

I understand that Massage Yogini does not provide prenatal massage services. I acknowledge that services may be declined at the therapist's discretion for safety reasons. I agree to disclose if I am pregnant and I acknowledge that I am responsible for communicating any changes in my health status, including pregnancy, prior to each session.

Are you currently ill?

Yes

No

Have you had a fever in the last 24 hours?

Yes

No

If yes, explain:

Are you currently injured?

Yes

No

Did the injury happen in the last 36 hours?

Yes

No

If yes, explain:

Have you had a massage before?

Yes

No

Chief complaint? Reasons or goals for seeking massage?

Look at the body images and select all areas that are bothering you below.

Right Side - Front - Left Side

Left Side - Back - Right Side

Pain Level:

Movement limitations, or areas to avoid?

Questions for practitioner:

Stress Level:

Low

Mild

Elevated

Severe

Physical Activity Level:

Mostly Inactive

Occasionally Active

Regularly Active

Very Active

*Massage Yogini, LLC