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Massage Intake Form For New Clients
Primary Physician
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Emergency Contact Full Name
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Emergency Contact Phone Number
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Emergency Contact Email
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Emergency Contact Relationship
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How did you hear about us?
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Are you taking medication(s)? If yes, please list:
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Are you currently pregnant?
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If Yes, How far along are you?
Any high risk factors?
Do you suffer from chronic pain?
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Yes
No
If yes, please explain:
When do you feel the most discomfort?
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Morning
Afternoon
Evening
Please Indicate any of the following that apply to you:
Joint Replacement
Cancer
Headaches/Migraines
None Applicable
Other
Have you had a professional massage in the past?
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What type of massage are you seeking?
Therapeutic
Medical
Relaxation
Deep Tissue
Other
If other, please explain:
Do you have any allergies or sensitivities?
Yes
No
If yes, please explain:
Is there any area you do not want to be touched on? (Face, Abdomen, Feet, etc)
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Please list area(s) we should avoid:
What are your goals for this session?
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