New Client Intake Form

Summerlin’s In-Home Massage & Cupping Therapy
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Your Birthday*

MonthDayYear
Gender*
How did you hear about me?*

Google SearchOtherReferral (type name below)Other
How often do you get a massage/bodywork?*
When was your last massage?*
Reason for booking a massage today?*
A deep, therapeutic massage can leave you feeling sore for a day or two. How do you feel about being sore after your massage?*
What areas would you like to focus on?*

Neck and ShouldersLow BackHips/GlutesLegsArms & HandsAll the above
In your entire lifetime, have you ever had any of the following surgeries?*

Any Orthopedic SurgeryCarpal Tunnel SurgeryRotator Cuff SurgeryNeck / Back FusionKnee SurgeryHip ReplacementAnkle SurgeryNo SurgeriesOther
Please list any significant injuries to your joints, muscles, or bones.
Do you have an implanted electronic device in your body (like a Pacemaker)?*
Are you currently pregnant? (If answered yes, I will send you a pregnancy specific intake form)*
Are you currently taking any medications?*
If YES, what are they and what are you taking them for?
Anything else I should be aware of?

Medical History*

	Current	Past	Never
Cancer
High Blood Pressure
Low Blood Pressure
Cardiovascular Disease
Epilepsy / Seizures
Chronic Headaches / Migraines
Chronic Dizziness / Ringing Ears
Arthritis (rheumatoid, osteoarthritis)
Scoliosis / Kyphosis / Lordosis
Osteoporosis
Broken Bone
Allergies that Require an Epi-Pen
Diabetes / Insulin Resistance
Sensitive to Touch / Pressure
Easy Bruising
Shortness of Breath / Asthma
Chronic Numbness / Tingling
Neurological Condition (ALS, Parkinsons, etc)
Chronic Skin Rash
Highly Sensitive to Certain Smells or Fragrances
Fibromyalgia
Memory Loss / Confusion
TMJ Syndrome
Varicose Veins

Summerlin’s In-Home Massage & Cupping Therapy