Medical intake form
Which therapist did you choose
Claudia and Benjamin
Claudia and Matthias
Claudia and Marie Constance
Street Address Line 2
State / Province
Postal / Zip Code
Please enter a valid phone number.
Do you need an insurance receipt?
Date of Birth
What is your work?
Your posture at work
Work in front of a computer
1) Have you had any accidents / falls which left any aftereffects or pain?
Ex: Sprain, Herniated disc, Break, Dislocation ...
2) Do you have skeletal-muscle problems?
Ex: Arthritis, Osteoarthritis, Fibromyalgia, Sciatica, Bursitis, Tendinitis, Epicondylitis, Cramps ...
3) Have you undergone operations that left after-effects or pain?
4) Are you suffering from any illness? As:
Si oui, sont t’ils contrôlés?
5) Do you take medication?
6) Do you have varicose veins?
Blue and or purple veins on the legs
7) Are you pregnant?
If yes, how many weeks?
8) Do you play sports? If so, which ones and how many times per week?
Please draw where there’s tension and pain
10) What areas of your body do you want to AVOID during your massage session?
11) Which parts do you want MORE FOCUS on during your massage session?
Shoulders and neck
Hips and buttocks
Arms and hands
Face and head
12) What pressure do you like?
1 is Light, 5 is Deep Tissue
13) Do you have any other things about your health that we should know?
14) Where did you find us?
Consent and Waiver
I authorize the use of lotion, oil, and ointments to my body
I acknowledge that I have consulted a physician before undergoing this treatment. I understand that this is an alternative treatment and if there are any medical concerns, I need to talk to my physician.
I acknowledge that this massage therapy has no sexual intent and touching the therapist is strictly prohibited.
I release Spa Mobile for any responsibility in case of an accident, illness or injury.
I acknowledge that all information i provided in this form is true and accurate.
*This section is for the therapist*
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