You could make one up, asking relevant questions about contra-indications, such as does the client have any of the following: High/low blood pressure; recent thrombosis; recent infection; heart condition.
I go through my consult form with my new clients, rather than letting them fill it in - this means that I get to know them a little bit more, and helps them to relax if they are nervous - there is also an excellent thread you could look at for ideas:
http://www.massageplanet.net/forum/showthread.php?t=18430&highlight=consultation+forms