Body Work Intake Form
First Name
Last Name
DOB
Address
Email
Phone Number
Occupation
Employer
Primary Physician
Emergency Contact
Emergency Contact Relationship
Emergency Contact Phone Number
How did you hear about us?
Are you taking any medications?
Select an option
Yes - Please list below
No
Medication List
Are you currently pregnant?
Select an option
Yes - Please answer questions below
No
* If currently pregnant: How far along? Any high risk factors? *
Do you suffer from chronic pain?
Select an option
Yes - Please explain below
No
* Please explain chronic pain *
* What makes chronic pain feel better? *
* What makes chronic pain feel worse? *
Have you had any orthopedic injuries?
Select an option
Yes - Please explain below
No
* If yes, please list orthopedic injuries *
Please indicate any of the following that apply to you
Cancer
Headache/Migraines
Arthritis
Diabetes
Joint Replacement(s)
High Blood Pressure
Low Blood Pressure
Neuropathy
Fibromyalgia
Stroke
Heart Attack
Kidney Dysfunction
Blood Clots
Numbness
Sprains/Strains
N/A
* Please explain any conditions you checked *
Have you had a professional massage before?
Select an option
Yes
No
What pressure do you prefer?
Select an option
Light
Medium
Deep
Do you have any allergies or sensitivities?
Select an option
Yes - Please explain below
No
* Please explain any allergies or sensitivities *
Are there any areas (feet, face, abdomen, etc.) you do not want massaged?
Select an option
Yes - Please explain below
No
* Please list any areas you do not want massaged? *
Please list and explain main area(s) of discomfort
What are your goals for this treatment session?
By signing below, you agree to the following: I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time.
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