Client Intake Form

The People's Elbow · Alex Adamczyk, LMT · GA License #MT013193

Fill this out before your session so your time goes to the massage, not the clipboard. It takes about five minutes and goes straight to Alex. Fields marked * are required.

Today

Where are we today? (event or venue)

Chair or table? *

Chair Table

Client Information

Full name *

Date of birth

Phone *

Email *

Address

Occupation

How did you hear about us?

Emergency contact (name)

Emergency contact (phone)

Appointment date

Your Visit

Main reason for your visit / areas of concern *

Pain right now (0 = none, 10 = worst)

Currently under chiropractic care?

Yes No

If yes, with whom

Health History

Current medications

Allergies (incl. oils, lotions, scents)

Recent surgeries or injuries (with dates)

Are you pregnant?

No Yes

If yes, weeks

Recent illness or fever?

Areas of Focus

Tap a body area to cycle through pain, tension, and please avoid. Tap again to clear. Or just describe it below.

Front

Back

Pain Tension / tightness Please avoid

Where does it hurt or feel tight? (your words)

Pressure preference

Light Medium Firm Deep

Areas to avoid

Massage History & Preferences

Had massage before?

Yes No

Scent / aromatherapy sensitivity?

Anything that helps you relax, or that you would like us to know?

Informed Consent

I have read and agree to the informed consent above. *

Type your full name as your signature *

Date

Typing your name here is your electronic signature. The date, time, and device used are recorded with your submission.

Goes directly to Alex's inbox. Nothing is stored on this website.

Got it. Thank you.

Your intake is in Alex's inbox. There is nothing else to do before your session. If anything changes, just mention it when you sit down.

Back to booking · peoples-elbow.com

Your health information is kept confidential and used only to provide and coordinate your care. • The People's Elbow is not accepting clients under 18 at this time. • Prefer paper? Printable version