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Home
About Us
Services
Our Forms
Massage
Esthetician
Redefine Beauty
Medical Massage/Insurance
Chakra Instrument Tuning
CBD
Contact Us
Massage Intake
Massage
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Personal Information
Name
Phone (day)
Phone (evening)
Address
City/State/Zip
Date of Birth
Occupation
Employer
Email
Primary Physician
Emergency Contact
Relationship
Phone
How did you hear about us?
Medical Information
Are you taking any medications?
Yes
No
If yes, please list name and use:
Are you currently pregnant?
Yes
No
If yes, how far along?
Any high risk factors?
Do you suffer from chronic pain?
Yes
No
If yes, please explain
What makes it better?
What makes it worse?
Have you had any orthopedic injuries?
Yes
No
If yes, please list
Please indicate any of the following that apply to you.
Cancer
Headaches/Migraines
Arthritis
Diabetes
Joint Replacement(s)
High/Low Blood Pressure
Neuropathy
Fibromyalgia
Stroke
Heart Attack
Kidney Dysfunction
Blood Clots
Numbness
Sprains or Strains
Explain any conditions you have marked above:
Massage Information
Have you had a professional massage before?
Yes
No
What type of massage are you seeking?
Relaxation
Therapeutic/Deep Tissue
Other
Other
What pressure do you prefer?
Light
Medium
Deep
Do you have any allergies or sensitivities?
Yes
No
Please explain
Are there any areas (feet, face, abdomen, etc.) you do not want massaged?
Yes
No
Please explain
What are your goals for this treatment session?
Please list any areas of discomfort
Client Signature
Date
Submit
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