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New Client Intake Form

First name*

Last name*

Email*

Phone*

Date of Birth*

Day

Month

Year

Home Address

Emergency Contact Full Name

Emergency Contact Phone Number

Occupation

Referred By: (if applicable)

HEALTH INFORMATION

Are you currently taking any medications?*

Yes

No

If yes, please provide details.

Do you have any allergies? (oils, lotions, skin reactions, nuts etc.)*

Yes

No

If yes, please provide details.

Are you currently under medical supervision?*

Yes

No

If yes, please provide details.

Have you had any recent injuries or medical procedures in the past 2 years?*

Yes

No

If yes, please provide details.

Have you had joint replacement surgery?*

Yes

No

If yes, please provide details.

Do you have any areas of broken skin (rash, wounds, infection)?*

Yes

No

If yes, please provide details.

Are you pregnant?*

Yes

No

If yes, how many months and what is your due date?

Please indicate any conditions that apply to you:

Areas of swelling

Autoimmune disorder

Back / neck problems

Bleeding disorders

Blood clots

Bruise easily

Bursitis

Cancer

Contagious condition

Decreased sensation

Diabetes

Fibromyalgia

Headaches

Heart condition

Hypertension

Kidney disease

Multiple sclerosis

Neurological condition

Neuropathy

Osteoarthritis

Osteoporosis

Phlebitis

Sciatica

Seizures

Stroke

Tendinitis

TMJ disorder

Varicose veins

Vertigo / dizziness

Please describe any other injuries or health conditions:

MASSAGE INFORMATION

Have you had a professional massage before?*

Yes

No

Reason for massage.*

Pressure preference?*

Light

Medium

Firm

Please describe any specific areas of discomfort or concern.

Legal Acknowledgment (Important)

By signing below, I acknowledge that I am aware of the benefits and risks of massage therapy and that I have completed this form to the best of my knowledge. I also agree to inform my massage therapist of any health or medical changes.

Privacy Policy
Accessibility Statement

Terms & Conditions

Broome St, Waterloo NSW 2017, Australia

© 2025 by Body Synergy

Mob: +61402422992

Email: bodysynergytim@gmail.com

Real treatment. Real results. That's what we do at Body Synergy.

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