Intuitive Bodywork Intake Form
by Kelseyfaith24
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How did you hear about me?
What kind of physical activities do you do?
Are you currently pregnant?
Do you have any allergies or sensitivities?
Do you suffer from chronic pain? If yes, what makes it better or worse?
Have you had a professional massage before? If yes, how often?
Have you received a floor mat massage before?
What are you hoping to get out of this experience?
What pressure do you prefer?
Light
Medium
Deep
Are there any areas that you do not want massaged? (Feet, face, abdomen, etc.)
Any additional information that I should know about?
How would you rate your flexibility?
Very limited
Average
Flexible
Extremely flexible
By signing below, you agree to the following. I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time.
Date
-
Month
-
Day
Year
Date
Submit
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