Intake – Leon Therapeutics

Name *

First

Last

Preferred pronouns

Email *

Phone *

Home address *

Address Line 1

Address Line 2

City

State

Zip Code

Date of birth *//

Occupation *

Emergency contact number *

How did you hear about us? *

If other, please specify *

About you

The following information will be used to help plan safe and effective massage sessions. Please answer the questions to the best of your knowledge.

Have you had a professional massage before? *

Yes
No

How often do you receive massage therapy? *

Very rarely
Once or twice per year
Three or four times per year
Every month or every few weeks

Do you have any difficulty lying on your front, back, or side? *

Yes
No

Please explain the difficulty *

Do you have any allergies to oils, lotions, or ointments? *

Yes
No

Please describe what you're allergic to *

Do you have sensitive skin? *

Yes
No

Do you wear any of the following? (Tick all that apply)

Contact lenses
Dentures
Hearing aids

Do you sit for long hours at a computer, workstation or driving? *

Yes
No

Do you perform any repetitive movement in your work, hobby or whilst playing sports regularly? *

Yes
No

Do you experience stress in your work, family, or other aspect of your life? *

Yes
No

How do you think this stress has affected your health? (Tick all that apply) *

Is there a particular area of the body where you are experiencing tension, stiffness, pain or discomfort? *

Yes
No

Please describe where you're hurting *

In addition to alleviating any of the issues you have highlighted above, do you have any particular goals in mind for this massage session? *

Yes
No

Please describe what you'd like us to achieve *

Your medical history

In order to deliver a massage session that is safe and effective, we need some general information about your medical history.

Are you currently under medical supervision? *

Yes
No

Please explain *

Do you see a chiropractor? *

Yes
No

How often? *

Are you currently taking any medication? *

Yes
No

Please list the medications you are taking *

Do any of the following conditions apply to you? (Tick all that apply)

Please explain any condition that you have marked

Please describe anything else about your health history that you think would be useful for your massage practitioner to know to plan a safe and effective massage session for you

Clients under the age of 17 must be accompanied by a parent or legal guardian during the entire session.

Informed written consent must be provided by a parent or legal guardian for any client under the age of 17.

I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort.

I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such.

Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so.

I agree to the above terms

Please print your full name here *

Client Intake Questionnaire

About you

Your medical history

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