925-937-6600 2625 Pleasant Hill Road Pleasant Hill, California 94523 terilynn@thegirlslockerroom.net

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The Girl's Locker Room

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CLIENT INTAKE FORM NAME _____________________________________________________________________________________ STREET ADDRESS __________________________________________________________________________ PHONE (HOME) ___________________ (WORK) ______________________ (CELL) ____________________ E-MAIL ADDRESS ________________________________________ OCCUPATION ______________________ AGE (CIRCLE ONE): UNDER 18 (NEEDS PARENTAL CONSENT) 18-30 31-40 41-50 51-60 OVER 60 REFERRED BY ______________________________________________________________________________ IF NOT REFERRED, HOW DID YOU COME TO INQUIRE? (GOOGLE, YAHOO, CITYSEARCH, MERCHANTCIRCLE, YELLOW, YELLOWPAGES, SUPERPAGES, ANOTHER SEARCH ENGINE [WHICH ONE?], A PARTICULAR MASSAGE WEBSITE [WHICH ONE?], LIVING.WELL MAGAZINE AD, YELLOW PAGES DIRECTORY, ETC.) PLEASE GIVE DETAILS, SUCH AS THE KEYWORDS YOU USED FOR YOUR SEARCH, IF YOU REMEMBER.________________________________________________________________ ___________________________________________________________________________________________________________ The following series of questions are to familiarize the therapist with important information about you, the client. It is of the utmost importance that you take the time to answer these questions to the best of your ability. This will help the therapist meet your needs with your massage. Please notify your therapist of any changes in your medical condition. All information is confidential. Primary reason for appointment _________________________________________________________________ Have you had a professional massage before? Do you have any allergies? Do you have any skin conditions? Do you have any infectious conditions? Have you had any surgery? Do you have any spinal issues? Do you wear contact lenses or dentures? Do you have frequent headaches? Are you constantly tired? Do you have any heart issues? Do you have high blood pressure? Do you have varicose veins? Do you have any history of blood clots? Do you have any cancer? Do you have arthritis? Is there any other medical condition the therapist should be aware of? Please explain any "yes" answers to the above questions. ___________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Do you participate in any sports or exercise program regularly? If "yes", what and how often? ______________ ___________________________________________________________________________________________ Are you currently under a doctor's care? If "yes", please describe. ____________________________________ ___________________________________________________________________________________________ Are you taking any medications? If "yes", please describe. __________________________________________ ___________________________________________________________________________________________ Have you had any injuries in the past? If "yes", please describe. ______________________________________ ___________________________________________________________________________________________ FEMALE CLIENTS ONLY: Are you pregnant? If "yes", how many months? ____________________________ Is your menstrual period due within the next week? ________________________________________________ I, ____________________, understand that the massage therapy given here is for the purpose of stress reduction, relief from muscular tension or spasm, or for increasing circulation, and is not of a sexual nature. I understand the massage therapist does not diagnose illness, disease, or any other physical or mental disorder. As such, the massage therapist prescribes neither medical treatment nor pharmaceuticals, nor performs any spinal manipulations. It has been made very clear to me that this massage therapy is not a substitute for medical examinations and/or diagnosis and that it is recommended that I see a physician for any physical conditions. I have stated all my known medical conditions and take it upon myself to keep the massage therapist updated on my physical health. If I am under 18 years of age, a parent or parental guardian must also sign for approval of my getting massaged. Signature of client ____________________________________________ Date _________________________ Signature of parent (if under 18) _________________________________ Date _________________________