MASSAGE & TREAMENTS INTAKE FORM
216 Newtown Road NE, Calhoun, GA 30701
Personal Information
In order to serve you properly, please fill out all information below as accurately as possible. This information will help to plan a safe and effective massage session. Please answer your questions to the best of your knowledge.
Client Status (Prohealth Staff Only)
First Time
First Massage
Current - Updating
Full Name
*
First Name
Middle Name
Last Name
Birth Date
*
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Year
Gender
Male
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Relationship Status
Single
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Phone Number
*
Type only the numbers. No (,),/,-
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
Please Select
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State
Zip Code
Occupation
*
Title and Company Name
Emegency Contact
Full Name
Phone Number
123-456-7890
Who Reffered you to us?
Name or Company
Please select 1st visit payment method:
I have a Package
I have a Gift Certificate
Pay at Time of Service
I Prepaid this Visit
Someone is sharing a visit to me
Other
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Medical History
In order to serve you properly, please fill out all information below as accurately as possible. This information will help to plan a safe and effective massage session. Please answer your questions to the best of your knowledge.
Have you ever had a professional massage?
No
Yes
Other
Are you pregnant? (If applicable)
No
Yes, How far along?:
Other
Do you have any allergies to oils, lotions, or ointments?
*
No
Yes
If yes, please describe
Example: Essencial Oil, Laundry Detergent, etc...
Please list any medication you are currently taking:
*
Type N/A if not medication taken
Have you had any surgery?
*
No
Yes
If Yes, list type of surgery and when:
Do you suffer from seizure disorders or epilepsy?
*
No
Yes
If Yes, please describe:
Do you experience frequent headaches?
*
No
Yes
If Yes, How often?
Do you have cardiac or circulatory problems?
*
No
Yes
If Yes, please describe:
Please describe any broken bone in the past 2 years:
Do you have numbness or stabbing pains?
*
No
Yes
If Yes, please describe:
Do you have any difficulty lying on your front, back, or side?
*
No
Yes
If Yes, please describe:
Do you sit for long hours at a workstation, computer, or driving?
*
No
Yes
If Yes, please describe:
Do you perform any repetitive movements in your work, sports, or hobby?
*
No
Yes
If Yes, please describe:
Is there a particular area of the body where you are experiencing tension, stiffness, pain? Or other discomfort?:
*
Pain Frequency - Please select the most accurate and describe if needed:
Constant
Off/On
At Rest
With Any Motion
Other
At what time of the day is the pain at its worse?
Morning
Afternoon
Evening
During Sleep
Have you ever injured this area before?
*
No
Yes
If Yes, please describe:
Do you have any mental illness?
*
No
Yes
If Yes, please describe:
Do you have cardiac or circulatory problems?
*
No
Yes
If Yes, please describe:
Are you wearing:
Hearing aids
Dentures
Contact lenses
Have you ever been in an accident (automobile, work, etc.)
*
No
Yes
If Yes, please describe:
Past History:
Arthritis
Asthma
Diabetes I
Diabetes II
Emphysema
Glaucoma
Hay Fever, Allergies
Heart Disease
Hiatal Hernia or Reflux Disease
High Blood Pressure
HIV
Kidney Disease
Liver Disease or Hepatitis
Pneumonia or Pleurisy
Prostate Problems
Pneumatic FeverStroke
Sinus Problems
Thyroid Problems
Tuberculosis or Exposure to TB
Ulcers of the Stomach or Duodenum
Urinary Infection, Bladder, or Kidney
Base of skull
Dizziness
Fainting
Light-headedness
Pain in ears
Ringing in ears
Cancer
Other
Personal Habits:
Alcohol
Tobacco
Soft Drink
Coffee/Tea
Do you have any particular goals in mind for this session?
*
Type NA if none
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Terms and Conditions
Disclaimer, Policies, and Realease Consent
Social Media Photo/Video Release Form
Release Consent Form
Do you authorized Pro Health Wellness Center and Spa to take pictures and/or a video of you during your session (s)?
Yes
No
Please check mark according to what you agree:
I authorize and grant Prohealth Wellness Center and Spa to take my photos regarding my experiences with them.
I grant Prohealth Wellness Center and Spa} to use my photos on Facebook, Instagram, and other social media platform.
I allow Prohealth Wellness Center and Spa to edit, alter, copy, or distribute the photos for social media advertising and marketing.
I agree that the photos belong to Prohealth Wellness Center and Spa.
I understand that I will not receive any monetary compensation.
Can we use our name?
Complete Name
First Name
Nickname
Anonymous
By signing below, I affirm and certify that I answered all questions, that are complete, true, and correct to the best of my knowledge and belief. I agree and understand all the policies, terms, and conditions mentioned here; including: Assignment of Benefits, No-show/Cancellation Policy, and Social Media Photo Release.
*
Client/Guardian Signature
Submit
Should be Empty: