Client Intake Form

Emergency Assistance

If this is an emergency, call:

Client Information

First name

Last name

Date of birth

Occupation

Gender identification

Contact Information

Home Address

Email address

Phone number

Emergency Contact

Emergency contact is optional but helpful in rare situations.

Would you like to provide one?

Yes

Add another emergency contact

Primary Care Physician

Primary care provider is optional but can support coordination of care.

Would you like to provide your PCP?

Yes

First name

Last name

Address

Phone number

Medical History

Have you received massage therapy before?

Yes No

What worked well about previous massage or bodywork?

What could have made it better?

Are you pregnant?

Yes No Not sure

If yes, how far along?

Reasons for Visit

What’s the one thing you most want improved at your first session?

What else would you like improved, even if not right away?

What’s a longer-term goal you’d like to work toward?

How did you hear about us?

Please describe pending surgery

Please describe Other

Pressure and technique will vary throughout your session to match your body’s needs. Your therapist will check in as the session progresses. Please let your therapist know anytime you would like adjustments for comfort.

Bodywork Preferences

We tailor every session to your comfort. Draping is always provided for modesty and professionalism. Techniques may sometimes involve areas like hips, glutes, abdomen, or upper inner thigh (inguinal area) if these areas contribute to your goals. Treatment areas are always your choice.

Areas you prefer we avoid:

Type none if none

Areas needing special attention:

Type none if none

Massage therapy and related services can sometimes be perceived by the body as a form of exercise or physical stress. To help ensure your comfort and safety, please answer the following questions.

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?

Yes

Do you feel pain in your chest when you do physical activity?

Yes

In the past month, have you had chest pain when you were not doing physical activity?

Yes

Do you lose your balance because of dizziness or do you ever lose consciousness?

Yes

Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity?

Yes

Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?

Yes

Do you know of any other reason why you should not do physical activity?

Yes

Because you answered Yes to one or more of the above, please briefly describe below:

Mark the areas on the image where you are experiencing symptoms.

For each area you mark, note the primary pain type (e.g., sharp, dull), severity (1–10), and describe any other sensations.

Attire Guidance

Please wear or bring close-fitting fitness or biker shorts and a tank top or sports bra. Professional draping is always provided for hands-on bodywork.

Cancellation Policy

I understand and agree to provide at least 24 hours’ notice for cancellations or rescheduling. I understand late cancellations and no-shows may result in a fee.

Privacy Statement

Florida Bodywork protects your personal information in accordance with Florida law and HIPAA standards. We do not share your information with anyone without your written consent.

I consent to this prescreen and sharing health information.

I consent to receive bodywork services when appropriate.

I understand and agree to draping.

I understand my identity will be verified before treatment, as required by Florida law.

I consent to proceed with assessment and treatment

By typing my name below, I confirm that the information provided is accurate and that I have read and agreed to the statements above.

Full Name

Date

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