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New Customer Intake Form |
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*Your full
name: |
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*Street Address |
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*City: |
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*State |
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*Zip: |
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*Your date of
birth: |
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Email: |
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*Phone (home): |
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*Phone (work): |
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*Employer: |
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*Occupation: |
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*Emergency Contact Name: |
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*Emergency Contact #: |
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*Relationship: |
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*Referred By: |
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Marital Status: |
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Is this your first professional massage?: |
Yes |
No |
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If yes, how frequently do you get a massage: |
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What do you hope to accomplish from your massage ?: |
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Are you aware of any tension building spots in your body?: |
Yes |
No |
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If yes, location: |
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Describe Any surgeries, hospitalizations, accidents or injuries in the last 5 years: |
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Describe Any surgeries, hospitalizations, accidents of injuries more than 5 years ago: |
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What kind of care did you receive for your accidents or injuries?: |
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Do you feel that you have recovered from these events?: |
Yes |
No |
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Please Explain: |
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Do you have any ongoing chronic pain that you have to deal with?: |
Yes |
No |
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Please Explain: |
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Describe what activities cause this pain and/or make it worse: |
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Are you receiving any other type of medical treatment: |
Yes |
No |
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Please Explain: |
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Please list any medications (vitamins, herbs, or pharmaceutical) taken now or at regular intervals (include explanation of what medication is used to treat: |
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Are currently under the care of a physician?: |
Yes |
No |
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Please List Reason(s): |
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Please let us know of any other health or any other conditions so that we may customize your treatment to suit your needs:
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By checking this box I am stating that the above information is accurante and true to the best of my knowledge. I understand that massage therapies do not diagnose disease, prescribe medications or manipulate bones. I further understand that massage therapy is not a substitute dor medical assistance or examination. I take responsibility for alerting my practitioner to any physical, mental or emotional changes that occur with my health. I also understand that cancelled or missed appointments without 24-hour notice (medical emergencies excluded) may be charged for the full price of the missed session.
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