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Kauai Massages Therapy
Client Intake Form

The Massage Hut Coconut Market Place Kauai,HI
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print function and fill it out prior to arriving for your appointment.

Please note: Any information exchanged on this form or during a massage therapy session is considered confidential and used only to provide you with the best health care services possible.
Name __________________________________________ Address ________________________________________ City ___________________________________________ State _______ Zip _____________ Occupation _______________________________________________ Massage Time Preference? Time _____________ Day _____________ Place? Be Specific with Directions Locations So We Can Better Assist you - Write Your Hotel,Vacation Rental/Home On Kauai - Here - _______________________________________________		Birth Date _________________________ Telephone # _______________________ Business # ________________________ E-mail address: __________________________________ Would you like to receive occasional newsletters or specials via e-mail?______ Credit Card # Visa Master Discovery Most Magor Credit cards's Accepted Card Holder _____________ Credit Card # __________________________________ CVC# On Back _____________

How did you hear about me? Friend ______ Newspaper advertisement ______ Locally Owned Business Insert in Banner-Herald ______ Website ______		Have you received massage therapy before? __________ What kind(s)? __________________________________ 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 ____ Numbness / Tingling ____ Burning / Itching		____ Hypo or Hyperglycemia ____ Contagious Conditions ____ Muscle Sprain / Strain ____ Heart Attack / Stroke ____ Paralysis of any kind ____ Arthritis ____ Headaches
Please describe any other condition(s) not listed above _________________________________________ _______________________________________________________________________________________

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?_____________________________________________________________

_______________________________________________ Please mark the area(s) in the diagram where you are having pain or discomfort.
I have completed this health form to the best of my knowledge and consent to receive massage therapy. I understand that massage therapy is a therapeutic health aid and is non-sexual. I UNDERSTAND THAT MASSAGE THERAPISTS DO NOT DIAGNOSE ILLNESS, DISEASE OR ANY PHYSICAL OR MENTAL DISORDER; NOR DO THEY PRESCRIBE MEDICAL TREATMENT, PHARMACEUTICALS, OR PERFORM SPINAL THRUST MANIPULATIONS. I ACKNOWLEDGE THAT MASSAGE IS NOT A SUBSTITUTE FOR MEDICAL EXAMINATIONS OR DIAGNOSIS, AND THAT IT IS RECOMMENDED THAT I SEE A PRIMARY HEALTH CARE PROVIDER FOR THAT SERVICE. 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 case of an emergency, I will call ASAP to reschedule my appointment. If I miss a scheduled appointment without giving 24 hours' notice, I agree to pay any missed appointment charge applicable.
Name (signature) _________________________________________ Date _______________________

To make an appointment, call 808-635-2324.E-Mail sales@kauaimassages.com © 2008 Kauai Massages Out Call Bodywork Intake aForm