Client Intake Form | |||
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To ensure that your health and wellbeing are fully
considered before getting massage or bodywork, please take a few minutes to fill
out this form because some medical conditions or specific symptoms are sometimes
indicators that the session should be modified, delayed or not done at all
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| LAST name | Email Address | ||
| FIRST name | Phone Number | ||
| Address | |||
| Gender | Male Female | | Age | Height Weight |
| yes no | Do you frequently suffer from stress | | yes no | Do you bruise easily |
| yes no | Do you suffer from back pain | | yes no | Have you had any broken bones |
| yes no | Are you taking any medications | | yes no | Have you been in a recent accident |
| yes no | Are you pregnant | | yes no | Have you suffered a recent injury |
| yes no | Do you wearing contact lenses | | yes no | Do you have cardiac problems |
| yes no | Do you wear dentures | | yes no | Do you have circulatory problems |
| yes no | Do you have osteoporosis | | yes no | Do you have high blood pressure |
| yes no | Do you suffer from epilepsy or seizures | | yes no | Do you experience frequent headaches |
| yes no | Do you have any contagious disease | | yes no | Do you have varicose veins |
| Do you have any allergies? -
especially to oils/nuts? Please specify... | |||
| Do you have any numbness or stabbing pains anywhere? Please specify | |||
| Are you sensitive to touch or
pressure anywhere? Please specify... | |||
| Do you have tension or soreness in
a specific area? Please specify... | |||
| Have you had any surgeries in the
past 5 years? Please specify... | |||
| Do you have any other medical conditions or are you taking any medications I should know about? | |||
| Emergency Contact | |||