Health Intake FormPlease fill out the following information before your first appointment so that I can better serve you. Name * First Name Last Name Phone * (###) ### #### Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country DOB * MM DD YYYY Pronouns He/HIm She/Her They/Them Other Occupation Who may I thank for the referral? Referral Contact Phone or Email Health History Physician Diagnosis If you have a specific medical condition or specific symptoms, massage/bodywork may be contraindicated. A referral from your primary care provider may be required prior to service being provided. Please take a moment to review this list and check any that apply. Stress Diabetes Headaches Arthritis High Blood Pressure Epilepsy/Seizures Joint Pain/Swelling Varicose Veins Contagious Diseases Osteoporosis Allergies Easy Bruising Broken Bones (in the last 2 years) Injuries (in the last 2 years) Cardiac/Circulatory Issues Back Pain Numbness/Stabbing Pains Surgery (recent) Other Explanation Please provide further details regarding any of the above issues below. What are your treatment goals? List and prioritize symptoms/issues you would like me to address during your session. (ie., stress, anxiety, pain, stiffness, numbness/tingling, swelling, etc.): Are you pregnant? Yes No Are you wearing contact lenses? Yes No Are you wearing a hairpiece? Yes No Are you wearing dentures? Yes No Emergency Contact Name Who should I contact in the event of an emergency? Emergency Contact Phone Bodywork History Previous Experience * Have you ever experienced a professional massage or bodywork session? Yes No Touch * What type of pressure do you prefer? Light Medium Deep Unsure Consent for Treatment If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage or bodywork should not be construed as a substitute for medical evaluation, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe or treat any physical or mental illness and that nothing said in the course of the session given should be construed as such. Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner's part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session and I will be liable for payment of the scheduled appointment. Check the box below, to acknowledge and accept the terms of this agreement. * Yes, I understand and agree to terms described above. Thank you!