Palm Beach Massage and Bodywork
Client Health Intake Questionnaire
Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
If under 18 Parent or Guardian
First Name
Last Name
Guardian Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
General Symptoms
Rows
Yes
NO
Comments
Dizziness
Fatigue
Headaches
Difficulty Sleeping
Numbness
Other
Respiratory
*
Rows
Yes
NO
Comments
Chronic Cough
Bronchitis
Asthma
COPD
High Blood Pressure
Heart Disease
Other
GastroIntestinal
Rows
Yes
NO
Comments
Nausea
Bloating
Constipation
Abdominal Cramps
Acid Reflux
Other
Diseases
Rows
Yes
NO
Comments
Diabetes
Cancer Type
Epilepsy
Fibromyalgia
Multiple Sclerosis
Lymphodema
Other
Head & Neck
Rows
Yes
NO
Comments
Ear Aches or Ringing
Sore Throat
Sinus Pain
Dental Pain
Vertigo
Other
Cardiovascular
*
Rows
Yes
NO
Comments
High Blood Pressure
Heart Disease
PaceMaker
Poor Circulation
Varicose Veins
Other
Infections
Rows
Yes
NO
Comments
HIV/AIDS
Hepatitis
Athlete's Foot
Warts
Tuberculosis
Other
Skin
*
Rows
Yes
NO
Comments
Excessive Dryness
Bruise Easily
Psoriasis
Eczema
Shingles
Other
Gender Specific
Rows
Yes
NO
Comments
Prostate
Menstrual Cramps
Breast Pain
Pelvic Pain
Preganant- Due
Other
Joints & Muscle
*
Rows
Yes
NO
Comments
Osteoporosis
Rheumatoid Arthritis
Osteoarthritis
Bursitis
Tendonitis
Artificial Joints
Bulging Disk
Sciatica
Jaw Pain/TMJ
Neck/Whiplash
Frozen Shoulder
Shoulder Impingement
Plantar Fasciitis
Tennis/Golfer's Elbow
Carpal Tunnel
Sprains/Strains
Back Pain
Other Muscle or Joint Pain
Other Details
Rows
Comments
Surgeries
Orthopedic Implants
Conditions
Changes with weather
Medications
Physician
Excercise Type & Frequency
Sleep
Last Massage
How did you hear about us
Reason for Visit
Signature
If under 18 Parent or Guardian Signature
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: