Intake Form

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Preferred Phone Number*

Area CodePhone Number

Alternate Phone Number

Area CodePhone Number

Email*

example@example.com

Referred By*

Occupation*

Date of Birth*

Emergency name and phone*

Present symptoms and history:

SLEEP (check all that apply)

HEADACHES - # and Frequency (for example, 1x per week)

HEADACHE LOCATION (check all that apply)

APPETITE

StrongNormalPoorOther

BOWELS - # and Frequency (for example, 1x per day)

BOWEL CONSISTENCY

HardMediumSoftOther

THROAT (check all that apply)

CoughPainPhlegmOther

NOSE (check all that apply)

BlockedRunnyBleedsOther

EARS (check all that apply)

CHEST (check all that apply)

URINE (check all that apply)

MENSES (check all that apply)

PREGNANT?

YesNo

IF PREGNANT, HOW MANY MONTHS?

MENOPAUSE?

YesNo

IF YES, PLEASE DESCRIBE.

CHILDREN?

YesNo

IF YES, HOW MANY?

STIFF (check all that apply)

NUMBNESS (check all that apply)

SKIN (check all that apply)

ENERGY (check all that apply)

CONSTITUTION (check all that apply)

Catch colds easiltyProne to coldProne to heatOther

DIET - CRAVINGS (check all that apply)

ALCOHOL - # and Frequency (for example, 1 drink per day)

TOBACCO - # and Frequency (for example, 10 per day)

I understand that the massage/bodywork I receive is provided for the basic purpose of relaxation & relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure &/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 examination, diagnosis or treatment & that I should see a physician, chiropractor or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe or treat any physical or mental illness & that nothing said in the course of the session given should be misconstrued as such. Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions & answered all questions honestly. I agree to keep the practitioner updated as to my changes in my medical profile and understand that there shall be no liability on the practitioners part should I forget to do so. It is also understood that any illicit or sexually suggestive remarks or advances made by me will result in the immediate termination of the session & I will be liable for payment of the scheduled appointment.

All appointments and cancellations must be confirmed. (If we do not respond to your appointment request or cancellation, we did not receive it.) There is a 24-hour cancellation policy where you will be charged the full amount of the missed appointment. Regarding illness, if you feel like you are getting sick the day before, please cancel.

BY INITIALING HERE, YOU ARE INDICATING THAT YOU HAVE READ AND AGREE TO THE ABOVE TERMS.*