AlbuquerqueMassage.Com » Intake Forms | AlbuquerqueMassage.Com http://albuquerquemassage.com Massage Therapist Directory for Albuquerque, NM Thu, 18 Jun 2015 14:24:20 +0000 en-US hourly 1 https://wordpress.org/?v=4.2.22 Erin’s Massage Client Intake Form http://albuquerquemassage.com/erins-massage-client-form/ http://albuquerquemassage.com/erins-massage-client-form/#comments Mon, 08 Jun 2015 07:31:50 +0000 http://albuquerquemassage.com/newsite/?p=1237 View Full Post;]]>
Erin’s Massage Therapy Client Information Form
Instructions
Print this form. Fill out all applicable information and call Erin Martin at (505) 730-9523 to set an appointment.
Name _____________________________________________
Street. Add. ________________________________________
City ________________________ ST _____ Zip ___________
Occupation _______________________________
Referred By ________________________________________
Birth Date _______________________
Telephone # _____________________
Business # _____________________
Cell # ______________________
SSN ___________________________
Have you received Therapeutic Massage? Yes ___ No ____ If so, how often? ____________
What is the reason for your visit today? __________________________________________________
Are there any areas you want me to concentrate on?______________________________________
Do you prefer a deep or light massage?_______________ Do you like stretches?_____________
Are there any areas you wish not to treat?_______________________________________
Are you under the care of a physician or other health care practitioner?_________
If yes, for what?__________________________________________________________________
Are you pregnant? __________
If yes, what trimester?________
Are you having any problems that I should know about? _________________________________________________
If so, do you have a doctor’s consent?___________________________________________________
Do you want your abdomen massaged? _____________ Around Breast?_______________________
List any medications you are now taking and what they are used for: _________________________
Please check off any of the following conditions or symptoms which apply to you now or in the past:
____Allergies
____Recent Illness, Injury or Surgery
____Areas of Pain
____Contagious Condition/Disease
____Osteoporosis or Osteopenia
____Occupational Injury
____History or Treatment of Cancer
____Lymph Edema
____Kidney Problems
____Doctor’s Care
____High Blood Pressure
____Cardiac or Circulatory Problems
____Headaches
____Diabetes
____Epilepsy or Seizures
____Bruise Easily
____Chronic Fatigue
____Active Cancer
____Swelling
____Pregnancy
____Medications
____Low Blood Pressure
____Vein Problems
____Joint Problems
____Arthritis
____Broken Bones
____Stress
____Fibromyalgia
____Active Infection
____Liver Problems
____Abdominal Issues
____Other concerns
This massage is for therapeutic purposes only and completely NON-SEXUAL. Your cooperation is expected.
I understand the massage services are designed to be a health aid and are in no way to take the place of a doctor’s care when it is indicated. Information exchanged during any massage session is educational in nature and is intended to help you become more familiar and conscious of your own health status and is to be used at your own discretion.
CANCELLATION POLICY: A 24 hour cancellation notice is required. If I do not receive 24 hour notice you will be sent a bill for the missed appointment, and in the future you will be required to give a credit card when booking your appointment.
Your appointment time has been set aside especially for you. If you are unable to keep the appointment, then there must be enough notice given so others who are waiting have the opportunity to reserve that time.
Name (signature) _________________________________________ Date _____________________
Emergency Contact:______________________Phone________________Relationship_____________
]]> http://albuquerquemassage.com/erins-massage-client-form/feed/ 0 Masterpiece Massage Client Intake Form http://albuquerquemassage.com/masterpiece-intake-form/ http://albuquerquemassage.com/masterpiece-intake-form/#comments Mon, 08 Jun 2015 07:25:33 +0000 http://albuquerquemassage.com/newsite/?p=1234 View Full Post;]]>
Masterpiece Massage Therapy Client Information Form
Instructions
Print this form. Fill out all applicable information and call Karla Linden at (505) 340-9454 to set an appointment. You may also mail your form to 3916 Carlisle NE Suite A • Albuquerque, NM 87107
Name _____________________________________________
Address ________________________________________
City ________________________ ST _____ Zip ___________
Occupation ____________________________
How did you learn about me? _________________________________
Your Insurance Company (if applies) ___________________________
Adjustor ______________________________
Birth Date _______________________
Telephone # _____________________
Business # ______________________
SSN ___________________________
Your Email _____________________
Telephone # _____________________
Claim # _________________________
Have you received Massage Therapy or Bodywork before? _________ What Kinds? _________________________
How often? ___________________________________________________________________
Please check off any of the following conditions or symptoms which apply to you now or in the past:
____High Blood Pressure
____Contact Lens
____Low Back Pain
____Allergy to Nut Oils
____Osteoporosis
____Diabetes
____Pregnant
____Blood Clots
____Low Blood Pressure
____Varicose Veins
____Bursitis
____Skin Infections
____Hypo or Hyperglycemia
____Contagious Conditions
____Muscle Sprain / Strain
____Heart Attack / Stroke
____Arthritis
____Headaches
____Other Conditions
Please list and explain other conditions/symptoms you are or have experienced: __________
___________________________________________________________________________________
Have you had any serious or chronic illness, operations, or traumatic accidents? _______
If yes, please explain: ___________________________________________________________
____________________________________________________________________________________
Are you currently, or have you at any time within the last 12 months been under the care of a physician? ______
If so, for what condition?________________________________________________
____________________________________________________________________________________
Are you on any medication? _______ If yes, which ones? ________________________________
May I have permission to contact your Doctor / Therapist? ________
Doctor / Therapist Name: ______________________________ Telephone __________________
Do you exercise? _____ How many times per week? _____ For how long? __________________
What percentages of the foods you eat would you say are:
Grains _______ Fruits ______ Meats ______ Fish ______ Dairy ______ Vegetables ______ Desserts/Sugar ____ Junk Foods ____
How many ounces of water do you drink per day? ___________________________
Do you drink caffeinated beverages? _______ If so, how many bottles/cups per day of the following? Soda Pop______ Coffee________ Black Teas_________
Do you smoke cigarettes? _________ How many per day? __________
Do you consume alcohol? _________ How many drinks per: Day _____ Week _____
I have completed this health form to the best of my knowledge. I understand that Massage Therapy and Bodywork services are a therapeutic health aid and are non-sexual. They do not take the place of a physician’s care when indicated. Any information exchanged during a Massage or Bodywork session is confidential and is only used to provide you with the best health care services.
If I am not able to make a scheduled appointment, I agree to cancel the appointment 24 hours in advance by phone, unless I have an emergency. In this case, I will call ASAP to reschedule my appointment.
If I miss a scheduled appointment without giving 24 notice, I agree pay any missed appointment charge applicable.
I am responsible to pay for any Massage or Bodywork fees not paid for by my insurance company.
Name (signature) _________________________________________ Date _____________________
]]> http://albuquerquemassage.com/masterpiece-intake-form/feed/ 0 Janet Jordan Client Intake Form http://albuquerquemassage.com/janet-jordan-intake-form/ http://albuquerquemassage.com/janet-jordan-intake-form/#comments Mon, 08 Jun 2015 07:20:18 +0000 http://albuquerquemassage.com/newsite/?p=1230 View Full Post;]]>
Janet Jordan Massage Therapy Client Information Form
Instructions
Print this form. Fill out all applicable information and call Janet Jordan at (505) 268-9443 to set an appointment. You may also mail your form to 1110 Pennsylvania NE Suite A • Albuquerque, NM 87110
Name _____________________________________________
Address ________________________________________
City ________________________ ST _____ Zip ___________
Occupation ____________________________
How did you learn about me? ___________________________

Birth Date _______________________
Telephone # _____________________
Business # ______________________
SSN ___________________________
Your Email _____________________

Have you received Massage Therapy or Bodywork before? _________ What Kinds? ____________
How often? ___________________________________________________________________
Please check off any of the following conditions or symptoms which apply to you now or in the past:
____High Blood Pressure
____Contact Lens
____Low Back Pain
____Allergy to Nut Oils
____Osteoporosis
____Diabetes
____Pregnant
____Blood Clots
____Low Blood Pressure
____Varicose Veins
____Bursitis
____Skin Infections
____Hypo or Hyperglycemia
____Contagious Conditions
____Muscle Sprain / Strain
____Heart Attack / Stroke
____Arthritis
____Headaches
____Other Conditions
Please list and explain other conditions/symptoms you are or have experienced: __________
___________________________________________________________________________________
Have you had any serious or chronic illness, operations, or traumatic accidents? _______
If yes, please explain: ___________________________________________________________
____________________________________________________________________________________
Are you currently, or have you at any time within the last 12 months been under the care of a physician? _____
If so, for what condition?________________________________________________
____________________________________________________________________________________
Are you on any medication? _______ If yes, which ones? ________________________________
May I have permission to contact your Doctor / Therapist? ________
Doctor / Therapist Name: ______________________________ Telephone __________________
Do you exercise? _____ How many times per week? _____ For how long? __________________
What percentages of the foods you eat would you say are:
Grains _______ Fruits ______ Meats ______ Fish ______ Dairy ______ Vegetables ______ Desserts/Sugar ____ Junk Foods ____
How many ounces of water do you drink per day? ___________________________
Do you drink caffeinated beverages? _______ If so, how many bottles/cups per day of the following? Soda Pop______ Coffee________ Black Teas_________
Do you smoke cigarettes? _________ How many per day? __________
Do you consume alcohol? _________ How many drinks per: Day _____ Week _____
I have completed this health form to the best of my knowledge. I understand that Massage Therapy and Bodywork services are a therapeutic health aid and are non-sexual. They do not take the place of a physician’s care when indicated. Any information exchanged during a Massage or Bodywork session is confidential and is only used to provide you with the best health care services.
If I am not able to make a scheduled appointment, I agree to cancel the appointment 24 hours in advance by phone, unless I have an emergency. In this case, I will call ASAP to reschedule my appointment.
If I miss a scheduled appointment without giving 24 notice, I agree pay any missed appointment charge applicable.
I am responsible to pay for any Massage or Bodywork fees not paid for by my insurance company.
Name (signature) _________________________________________ Date _____________________
]]> http://albuquerquemassage.com/janet-jordan-intake-form/feed/ 0 Dancing Massage Client Intake Form http://albuquerquemassage.com/dancing-massage-intake-form/ http://albuquerquemassage.com/dancing-massage-intake-form/#comments Mon, 08 Jun 2015 06:57:57 +0000 http://albuquerquemassage.com/newsite/?p=1225 View Full Post;]]>
Dancing Massage Therapy Client Information Form
Instructions
Print this form. Fill out all applicable information and call Faith Harmony at (505) 299-2863 to set an appointment.
Name _____________________________________________
Address ________________________________________
City ________________________ ST _____ Zip ___________
Occupation ____________________________
How did you learn about me? ___________________________
Your Insurance Company (if applies) _____________________
Adjustor ________________________

Birth Date _______________________
Telephone # _____________________
Business # ______________________
SSN ___________________________
Your Email _____________________
Telephone # _____________________
Claim # _________________________

Have you received Massage Therapy or Bodywork before? _________ What Kinds? ____________
How often? ___________________________________________________________________
Please check off any of the following conditions or symptoms which apply to you now or in the past:
____High Blood Pressure
____Contact Lens
____Low Back Pain
____Allergy to Nut Oils
____Osteoporosis
____Diabetes
____Pregnant
____Blood Clots
____Low Blood Pressure
____Varicose Veins
____Bursitis
____Skin Infections
____Hypo or Hyperglycemia
____Contagious Conditions
____Muscle Sprain / Strain
____Heart Attack / Stroke
____Arthritis
____Headaches
____Other Conditions
Please list and explain other conditions/symptoms you are or have experienced: __________
___________________________________________________________________________________
Have you had any serious or chronic illness, operations, or traumatic accidents? _______
If yes, please explain: ___________________________________________________________
____________________________________________________________________________________
Are you currently, or have you at any time within the last 12 months been under the care of a physician? _____
If so, for what condition?________________________________________________
____________________________________________________________________________________
Are you on any medication? _______ If yes, which ones? ________________________________
May I have permission to contact your Doctor / Therapist? ________
Doctor / Therapist Name: ______________________________ Telephone __________________
Do you exercise? _____ How many times per week? _____ For how long? __________________
What percentages of the foods you eat would you say are:
Grains _______ Fruits ______ Meats ______ Fish ______ Dairy ______ Vegetables ______ Desserts/Sugar ____ Junk Foods ____
How many ounces of water do you drink per day? ___________________________
Do you drink caffeinated beverages? _______ If so, how many bottles/cups per day of the following? Soda Pop_____ Coffee_____ Black Teas_____
Do you smoke cigarettes? _________ How many per day? __________
Do you consume alcohol? _________ How many drinks per: Day _____ Week _____
I have completed this health form to the best of my knowledge. I understand that Massage Therapy and Bodywork services are a therapeutic health aid and are non-sexual. They do not take the place of a physician’s care when indicated. Any information exchanged during a Massage or Bodywork session is confidential and is only used to provide you with the best health care services.
If I am not able to make a scheduled appointment, I agree to cancel the appointment 24 hours in advance by phone, unless I have an emergency. In this case, I will call ASAP to reschedule my appointment.
If I miss a scheduled appointment without giving 24 notice, I agree pay any missed appointment charge applicable.
I am responsible to pay for any Massage or Bodywork fees not paid for by my insurance company.
Name (signature) _________________________________________ Date _____________________
]]> http://albuquerquemassage.com/dancing-massage-intake-form/feed/ 0 Advanced Massage Client On-Line Intake Form http://albuquerquemassage.com/advanced-massage-intake-form/ http://albuquerquemassage.com/advanced-massage-intake-form/#comments Mon, 08 Jun 2015 03:19:18 +0000 http://albuquerquemassage.com/newsite/?p=1204 View Full Post;]]>
Advanced Massage Therapy Client Information Form
Instructions
Print this form. Fill out all applicable information and call Greg Anderson at (505) 489-3903 to set an appointment.
Name _____________________________________________
Street. Add. ________________________________________
City ________________________ ST _____ Zip ___________
Occupation ___________________Marital Status? ________

Birth Date _______________________
Telephone # _____________________
Business # ______________________
SSN ___________________________

Have you received Therapeutic Massage? Yes ___ No ____ If so, how often? ____________
What is the reason for your visit today? __________________________________________________
Are there any areas you want me to concentrate on?______________________________________
Do you prefer a deep or light massage?_______________ Do you like stretches?_____________
Are there any areas you wish not to treat?_______________________________________
Are you under the care of a physician or other health care practitioner?_________
If yes, for what?__________________________________________________________________
Are you pregnant? __________ If yes, what trimester?________
Are you having any problems that I should know about? _________________________________________________
If so, do you have a doctor’s consent?___________________________________________________
Do you want your abdomen massaged? _____________ Around Breast?_______________________
List any medications you are now taking and what they are used for: _________________________
Please check off any of the following conditions or symptoms which apply to you now or in the past:
____serious injuries
____blood clots
____allergies
____high blood pressure
____contagious conditions
____AIDS
____stroke
____low blood pressure
____skin infections
____heart attack
____recent surgery
____arthritis
____varicose veins
____back pain
____use of tobacco
____contacts
____diabetes
____allergy to perfumes or oils
____other
This massage is for therapeutic purposes only and completely NON-SEXUAL. Your cooperation is expected.
I understand the massage services are designed to be a health aid and are in no way to take the place of a doctor’s care when it is indicated. Information exchanged during any massage session is educational in nature and is intended to help you become more familiar and conscious of your own health status and is to be used at your own discretion.
CANCELLATION POLICY: A 24 hour cancellation notice is required. If I do not receive 24 hour notice you will be sent a bill for the missed appointment, and in the future you will be required to give a credit card when booking your appointment.
Your appointment time has been set aside especially for you. If you are unable to keep the appointment, then there must be enough notice given so others who are waiting have the opportunity to reserve that time.
Name (signature) _________________________________________ Date _____________________
Emergency Contact:______________________Phone________________Relationship_____________
If you would like to receive notification of specials please give me your email address: __________________________________________
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