Our Location

23 Diamond Spring Rd

Denville, NJ

07834

Our Hours

Monday: 10:00 am - 5:00 pm
Tuesday: Closed
Wed - Sun: 2:00 pm - 10:00 pm

Our Number

(908) 455-4665

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Book Now

Home
About Us
- FAQs
- Resources
Services
Areas We Serve
Reviews
Gallery
Contact Us

(908) 455-4665

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Client Intake & Health History For

Please complete this form before your session. The information you provide will help your therapist understand your health history, identify potential precautions, and tailor your session to your needs. All information will be treated confidentially and handled appropriately.

CLIENT INFORMATION

First name This is required

Last name This is required

Date of Birth This is required rt.advancedFormInput.date.formatMessage

Age This is required

Email Enter an email Use an address with (@) and (.)

Phone number Enter your phone number Enter a valid number like +1555-123-4567

Street Address This is required

City This is required

State This is required

Zipcode This is required

Emergency Contact This is required

Relationship This is required

Emergency Contact Phone number Enter your phone number Enter a valid number like +1555-123-4567

Date of Intake This is required rt.advancedFormInput.date.formatMessage

WHAT BRINGS YOU IN TODAY?

What is the primary reason for your visit?

Check all that Apply.

Relaxation / Stress Relief

Muscle Tension / Tightness

Neck Pain or Stiffness

Shoulder Pain or Restriction

Upper Back Pain

Lower Back Pain

Hip Pain or Mobility Issues

Headaches / Migraines

TMJ / Jaw Tension

Sciatica / Nerve-Related Symptoms

Sports Performance / Recovery

Injury Rehabilitation

Post-Surgical Recovery

Improve Flexibility / Range of Motion

General Wellness / Maintenance

Other

This is required

Please Explain This is required

Please describe your main concern or reason for today’s session: This is required

When did the problem or symptoms begin? This is required

Is the issue? This is required

What makes your symptoms worse? This is required

What makes your symptoms better? This is required

On a scale of 0–10, how would you rate your current discomfort? This is required

Does this condition affect your daily activities, work, sleep, exercise, or mobility? This is required

HEALTH HISTORY & MEDICAL CONDITIONS

Have you ever been diagnosed with, or are you currently experiencing, any of the following?

Check all that apply

High Blood Pressure

Low Blood Pressure

Heart Disease / Cardiovascular Condition

History of Stroke

Diabetes

Cancer / History of Cancer

Arthritis / Osteoarthritis / Rheumatoid Arthritis

Osteoporosis / Osteopenia

Fibromyalgia / Chronic Pain

Neurological Condition

Parkinson’s Disease

Multiple Sclerosis

Seizure Disorder

Numbness / Tingling / Nerve Symptoms

Blood Clots / DVT

Varicose Veins

Circulation Problems

Lymphedema / Significant Swelling

Autoimmune Disorder

Respiratory Condition / Asthma

Skin Condition / Infection / Open Wounds

Recent Fever / Contagious Illness

Hernia

Disc Herniation / Spinal Condition

Recent Fracture / Sprain / Strain

Recent Surgery

Pregnancy / Postpartum

Allergies / Sensitivities

None of the above

Other

This is required

Please Explain This is required

Are you currently under the care of a physician, chiropractor, physical therapist, or other healthcare provider? This is required

Please Indicate provider type and reason for care: This is required

Have you had any surgeries, significant injuries, or hospitalizations? This is required

Please describe and include approximate dates: This is required

Do you have any current medical restrictions or have you been advised to avoid massage or certain types of physical pressure? This is required

Please Explain: This is required

MEDICATIONS & ALLERGIES

Are you currently taking any prescription medications, over-the-counter medications, vitamins, or supplements? This is required

Please list the name, dosage if known, and reason for use. This is required

Do you have any known allergies or sensitivities?

Oils / Lotions

Fragrances

Latex

Adhesives

Other

None known

This is required

Please Explain: This is required

LIFESTYLE & TREATMENT HISTORY

Activity level: This is required

Occupation / Typical daily activities: This is required

How often do you receive massage or bodywork? This is required

Are there any areas you do not want treated, or areas requiring extra caution? This is required

Preferred pressure: This is required

HOW DID YOU HEAR ABOUT US?

Friend / Family Referral

Existing Client Referral

Physician / Chiropractor / Healthcare Provider

Google / Online Search

Business Website

Facebook

Instagram / TikTok / Other Social Media

Community Event / Flyer

Returning Client

Other

This is required

Please Explain This is required

If referred by someone or a healthcare provider, may we ask who referred you? This is required

CLIENT ACKNOWLEDGMENT & CONSENT

Please read and acknowledge the following statements.

I confirm that the information provided on this form is accurate and complete to the best of my knowledge. I agree to inform my therapist of any changes to my health, medications, symptoms, or medical status.

This is required

I understand that massage therapy and bodywork are intended to support relaxation, mobility, and general wellness and are not a substitute for medical diagnosis or treatment.

This is required

I understand that I may communicate my preferences, request changes in pressure or technique, ask questions, or stop the session at any time.

This is required

I understand that my therapist may modify, postpone, or decline treatment when a condition or symptom indicates that massage may be unsafe or that medical evaluation is appropriate.

This is required

I understand that my consent is voluntary and that any treatment involving sensitive areas requires appropriate discussion and specific consent.

This is required

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