Massage/ Polarity Therapy Client Intake Form
Amanda Lux, LMT, BCPP
Name___________________________________________________________ Date_____________________
Cell Number______________________
Emergency Contact _________________________________________________________________________
Name Relationship Number
Please choose a number between 1-5 to represent your pain level: __________
(Low 1 2 3 4 5 High)
Please choose a number between 1-5 to represent your stress level: __________
(Low 1 2 3 4 5 High)
Are you pregnant? __________Yes ____________No
Are you on any medications that we should know about?
Do you have an acute injury or suffer from chronic pain? __________Yes ____________No
Please Explain:
What areas would you like your therapist to focus on or avoid?
What is your intention and/ or desired outcome for this session?
1