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RAP Manual Therapy Intake Form

Name: RAP Manual Therapy and Massage
Price range: $$$

Quick health intake – takes only 2 minutes! This helps us keep you safe, avoid contraindicated areas, and give you the most relaxing and effective session possible. Everything is completely confidential. Thank you!

Client Information

Name *

Date of Birth *

Phone *

Email Address *

Street Address *

Apartment, suite, etc

City *

State/Province

ZIP / Postal Code

Other:

Emergency Contact

Name *

Phone *

Relationship to You

Health History & Contraindications

Surgical history (list any past surgeries and dates, if known)

Do you have a history of blood clots, deep-vein thrombosis, or bleeding disorders?NoYes

please explain:

Do you have any implants, metal plates, pins, pacemaker, stents, or surgical mesh?NoYes

please explain:

Allergies (latex, oils, scents, medications, etc.)NoYes

please explain:

Current medications (prescription, over-the-counter, supplements)

Have you been hospitalized or had any major illness in the past 12 months?NoYes

please explain:

Do you have any current injuries? *

please explain:

Areas of tension, soreness, or pain you would like addressed today

Are you currently pregnant or nursing?NoPregnantNursing

weeks/trimester:

Consent and Waiver

Electronic Signature *By typing my full name, I confirm this serves as my legal electronic signature.

Today

RAP Manual Therapy Intake Form

Client Information

Emergency Contact

Health History & Contraindications

Consent and Waiver

Hours of Operation

Contact Information

Massage and Yoga Music

Massage Oils