FM
Forever Massage of Traditional Chinese Inc.
Rehabilitation & Massage Therapy Department • Traditional Chinese Wellness
Form No.FM-HOSP-INTAKE-01
DepartmentOutpatient Intake
Effective Date2026-04-02
Hospital-Style Intake Record Confidential Medical Intake Record Identity verified • Consent required
Patient ID: ____________________ Chart No.: ____________________ Checked by: ____________________
CONFIDENTIAL HEALTH HISTORY FORM
An accurate Health History is important to ensure that it is safe for you to receive a massage treatment. All information gathered for this treatment is confidential except as required or allowed by law. Written authorization will be required for release of any information. 24 hours cancellation notice is required.
Personal Details
Name:
M/F:
DOB:
Phone:
Email:
Address / City / Postal Code:
Occupation:
First Massage?
Family Physician:
News/Offers?
Emergency Contact (Name/Phone):
Referred by:
Reason for Treatment:
Body Map (Mark Pain/Stiffness)
ANTERIOR (FRONT)
POSTERIOR (BACK)
Tap / click the body to place a marker. Drag only when using Shade or Eraser. Use Clear on each side or Clear All to remove markings.
NNumbness SSoreness TTingling / Tenderness Shade = Pain / Stiffness
Clinic Body Map Notes
5
Draft autosave: ON
* PLEASE COMPLETE BACK OF FORM
Clients Initial:
© 2026 All Rights Reserved. Unauthorized reproduction or imitation of this document is strictly prohibited and subject to legal action.

Scan to share

Soft Tissue/Joints
Location:
Headaches
Head trauma-date: ×
Accident/Injury
Date: ×
Symptoms:
Physical limits:
Women
Pregnant/due date: ×
Respiratory
Cardiovascular
Infectious Disease
Other:
Skin
Other conditions
Specify:
Digestive conditions:
Specify:
Surgery/Other Conditions? Y/N Type: Date: ×
Current Symptoms:
Current Medication/Treatments/Health Care Programs (specify):
General Health Status:        
Therapist Clinical Impression / Treatment Plan

I understand that massage therapists do not diagnose illness, prescribe medications or make spinal adjustments. I further understand that massage therapy is not a substitute for medical care or treatment. I have alerted my massage therapist to any conditions I have which may affect the work and have disclosed all medications (pharmaceutical, herbal or any other forms) that I am currently taking. I take it upon myself to update the massage therapist regarding any changes in my mental, emotional or physical health condition (current and in future).

I am seeking therapeutic massage on my own accord for the purposes that massage is intended. Such purposes include but are not limited to relaxation, mental wellness, relieving tension of sore muscles, improved circulation and/or improved range of motion. I understand that all massage treatments will be discussed and planned with the massage therapist and will require my informed consent. The Massage Therapist reserves right to reject customers and end massage treatment at any time; reasons can be but are not limited to health concerns, conditions which contraindicate massage, not sufficient health information is given.

Client Printed Name: Date: ×
Client Signature
Client Signature Preview
No signature yet / 点击上方按钮签字
Please sign before saving PDF
© 2026 All Rights Reserved. Unauthorized reproduction or imitation of this document is strictly prohibited and subject to legal action.