| Client Intake Form Body Restoration Massage Page 1 Las Vegas Nevada 702 524 5686 Please Print & Fill Out This Intake Form For My Records Therapeutic Massage Confidential Health Intake Form Name ______________________________________Address_________________________________________________________________ WorkPhone_____________________Home Phone____________________Cell Phone_____________________Date of Birth____________ Email ______________________________________________Emergency Contact-optional________________________________________ CURRENT HEALTH ISSUES What is your main reason for having a Session? __________________________________________________________________________ Has anything changed or become worse recently?_________________________________________________________________________ List any other health problems that are troubling you._______________________________________________________________________ Are you currently taking any prescription drugs and if so what are they? Some prescription drugs can be effected by massage. Please List:_________________________________________________________________________________________________________________________ Have you ever had a professional massage before?_________________________________________________________________________ If yes, what do you like best about massage?_______________________________________________________________________________ If yes, how often do you receive massage therapy?_________________________________________________________________________ Is there anything you disliked about your previous massages?_______________________________________________________________ Do you have a style or pressure preference? Specify: Light Medium Deep Trigger Point Other What type of massage are your seeking today? Relaxation Deep Tissue/Therapeutic Senior Pre-Natal/Post-Natal Integrated Bodywork (mixed-functional) Pain Relief Other_________________________________________________________________ Are you sensitive to fragrances or perfumes?____________Do you have sensitive skin?_________________________________________ Do you have body hair that is sensitive to being rubbed?________________Do you wear contact lenses?___________________________ Do you exercise regularly?___________If so, what type (s)? ___________________________ Pain with exercise?_____________________ What is your common areas of pain tension?________________________________________________________________________________ Do you suffer from chronic or persistent pain/discomfort?_______________If so, how long?_______________________________________ Where?_______________________________________________________________________________________________________________ Do you know what caused it or when the symptoms seem to get worse or better?_______________________________________________ ___________________________________________________________________________________________________________________________________ Do you see a chiropractor?___________________________If so, how often?___________________ Explain anything above: |
