Sam Chi Health Client Intake Form

Massage Therapy | CranioSacral Therapy | LED Light Therapy


Name___________________________ Phone (Day) ___________________Cell____________________


Email______________________________________ Occupation _________________________________

Date of Birth___________ Referred by ______________________________________________________

Emergency Contact ____________________________________________ Phone___________________


The following information will be used to help your therapist plan a safe and effective massage

session.  Please answer the questions to the best of your knowledge.


Have you had a professional massage before?  Yes  No    If yes, how often? ________________________

Do you have any difficulty lying on your front, back, or side?    Yes    No

If yes, please explain ______________________________________________________________

Do you have any allergies to oils, lotions, ointments, fruits or nuts?    Yes    No

If yes, please explain ______________________________________________________________

Do you have sensitive skin?    Yes    No  

Are you wearing _ contact lenses __dentures _ a hearing aid _ prosthetics?

Do you sit for long hours at a workstation, computer, or driving?    Yes    No

If yes, please describe _____________________________________________________________

Do you perform any repetitive movement in your work, sports, or hobby?   Yes   No

If yes, please describe _____________________________________________________________

How do you feel the stress in your work, family, or other aspect of your life affected your health? 

__muscle tension      __anxiety       _ insomnia        __irritability       __other___________________

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

Yes    No     If yes, please identify____________________________________________________

Do you have any particular goals in mind for this massage session?    Yes    No

If yes, please explain______________________________________________________________


Circle any specific areas you would like the massage therapist to concentrate on during the session:



Medical History

Do you currently or have you ever had any of the following: (please check)

_ Phlebitis _ Tennis elbow

_Deep vein thrombosis/blood clots __Recent fracture

_ Joint disorder __Recent surgery

_ Rheumatoid arthritis/osteoarthritis/tendonitis __Artificial joint

_ Osteoporosis __Sprains/strains

_ Epilepsy __Current fever

_ Headaches/migraines __Swollen glands

_ Cancer __Allergies/sensitivity

_ Diabetes __Heart condition

_ Decreased sensation __High or low blood pressure

_ Back/neck problems __Circulatory disorder

_ Fibromyalgia __Varicose veins

_ TMJ __Atherosclerosis

_ Carpal tunnel syndrome __Easy bruising

__Contagious skin condition                                         __Recent accident or injury_

__Open sores or wounds                                              __ Pregnancy If yes, how many months?


Are you currently under medical supervision?    Yes    No

If yes, please explain_______________________________________________________________


Do you see a chiropractor? Yes No       If yes, how often? _______________________________________

Are you currently taking any medication?    Yes    No

If yes, please list _________________________________________________________________

Is there anything else about your health history that you think would be useful for your massage therapist to

know to plan a safe and effective massage session for you?  ____________________________________


I understand that the Massage Therapy, CranioSacral Therapy or Phototherapy (LED) Light Therapy

I receive is provided for the basic purpose of relaxation and relief of muscular tension.

If I experience any pain or discomfort during my 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 Therapy, Craniosacral Therapy or LED Red Light Therapy should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician

or another qualified medical specialist for any mental or physical ailment that I am aware of. I understand that Wellness Massage Providers are not qualified to perform 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.


Signature of Client ______________________________________________ Date ___________________


Signature of Massage Wellness Provider, Craniosacral, Professional Laser Therapist, Kamloops, British Columbia, Canada


____________________________________________________________ Date ___________________