Medical intake form
Client File
Name
*
First Name
Last Name
Which therapist did you choose
*
Please Select
Claudia
Lydia
Benjamin
Gabrielle
Matthias
Jennie
Marie Constance
Claudia and Benjamin
Claudia and Matthias
Claudia and Marie Constance
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Do you need an insurance receipt?
Yes
No
Date of Birth
*
-
Month
-
Day
Year
Date
What is your work?
*
Your posture at work
*
Mostly Sitting
Mostly standing
Work in front of a computer
Other
You are
*
Left handed
Right handed
Both
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:
Cholesterol
Hypertension
Hypotension
Diabetes
Thyroid
Asthma
Atherosclerosis
Angina
Infarction
Stroke
Cancer
Emphysema
Other
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?
*
Yes
No
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?
The glutes
The feet
The head
The abdomen
Other
11) Which parts do you want MORE FOCUS on during your massage session?
The back
Lower back
Shoulders and neck
Hips and buttocks
Legs
Foot
Arms and hands
Face and head
Autre
12) What pressure do you like?
*
Light
1
2
3
4
Deep Tissue
5
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?
*
Google
Instagram
Facebook
Referred
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.
Client’s Signature
*
Signature
Clear
Submit
*This section is for the therapist*
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