Bodywork by Amy New Client Intake Form

Bodywork by Amy

Client Intake Form
Full Name:*
Phone Number*
D.O.B*

MonthDayYear
Email:*
example@example.com
Home Address*
Occupation*
Or hobbies that help me understand any repetitive movements of the body.
Reason for session:
Please describe the tension/pain/situation you're experiencing.
Are you currently pregnant? If so, how far along are you?*
Are you experiencing a fever or any flu-like symptoms?*
Please reschedule appointment if you have been exposed to Covid-19, or are experiencing any illness-related symptoms such as fever, chills, sore throat, cough, etc.
Medical/Trauma history Including accidents and surgeries:*
Allergies *
I use a organic, nut-free massage oil, but list any sensitivites you may have to any ingredients or environmental allergies.
Medications:*
Massage therapy is not a substitute for professional medical care or counseling. I do not diagnose or prescribe medications of any kind. I may refer you to another healthcare provider if you are experiencing a condition that is contradictory to massage therapy. All information that is shared during the massage session is held strictly confidential.

There is no sexual massage of any kind with Bodywork by Amy.

By signing below, I do hereby acknowledge that the above information that I provided is compete and accurate. I stated all my known medical conditions and medications and I will inform the massage therapist of any changes in my health status. I also understand the scope of massage therapy practice and the policies listed above.
Signed*

Clear
Date:*

MonthDayYear
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