THE PLUG kNOw Comfort in Silence Massage
Client Intake Form
Basic Information
Full Name:
First Name
Last Name
Date of Birth:
-
Month
-
Day
Year
Date
Phone Number:
Format: (000) 000-0000.
Email Address:
example@example.com
Emergency Contact Name & Number:
General Health History
Do you have any current medical conditions? (If yes, explain):
Are you currently under a doctor's care?:
Are you taking any medications or supplements?:
Do you have any allergies? (oils, lotions, latex, etc.):
Have you had any recent surgeries? (within 6-12 months):
Circulatory & Internal Health
History of blood clots?:
Heart conditions or high blood pressure?:
Diabetes?:
Liver or kidney disease?:
Swelling or fluid retention?:
Skin & Body Conditions
Skin conditions? (eczema, rashes, open wounds):
Do you bruise easily?:
Do you have varicose veins?:
Any recent injuries or inflammation?:
Back
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Massage Preferences & Needs
Have you had a professional massage before?:
Preferred pressure (light, medium, deep)?:
Areas of pain, tension, or injury?:
Areas you want to avoid?:
Do you experience chronic pain? (neck, back, etc.):
Lifestyle
How often do you exercise?:
Daily water intake?:
Alcohol consumption?:
Smoking?:
Contraindications
Fever or illness:
Contagious conditions:
Recent fractures:
Severe inflammation:
Open wounds or infections:
Consent
I understand massage is not a medical treatment:
I confirm information provided is accurate:
I consent to receive massage services:
Signature:
Date:
-
Month
-
Day
Year
Date
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Submit
Should be Empty: