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Massage Therapy Intake Form
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Indicates required field
Name
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First
Last
Address
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Line 1
Line 2
City
State
Zip Code
Country
Email
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Date of Birth
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Phone Number
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Emergency Contact
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First
Last
Phone Number
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Have you received professional massage therapy before?
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Yes
No
If "yes," how often, and how long ago was your last session?
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Understanding that different areas of the body often prefer differing depths of pressure, if "yes," what is your general preferred depth of pressure?
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Light
Medium/Firm
Almost painful
What is your reason for seeking massage therapy? Check all that apply.
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Relaxation
Physical Trauma Rehabilitation
Emotional Trauma Rehabilitation
Holistic Wellness Maintenance/Disease Prevention
Other
Please Describe:
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Do you experience chronic or persistent physical pain or discomfort?
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Yes
No
If "yes," where and for how long?
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Are there any areas of your body you prefer to not be touched?
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Yes
No
Do you allow yourself regular physical activity? If so, how often?
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Medical History
Do you currently regularly see a physician?
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Yes
No
What is the cause or contributing factor(s)?
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If "yes," please list here:
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If "yes," please describe:
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Do you currently regularly see a mental healthcare provider?
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Yes
No
Do you currently regularly see an energy work provider?
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Yes
No
Are you currently taking any prescription medications or herbal supplements?
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Yes
No
Have you undergone any surgery?
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Yes
No
Is there any chance you may currently be pregnant?
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Yes
No
Do you have any allergies or sensitivities?
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Yes
No
If "yes," please describe:
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If "yes," please describe:
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If so, what are they; and for what reason(s)?
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If "yes," for what, and how long ago?
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If "yes," please describe:
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Check all conditions that you experience regularly or often:
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Headaches
Arthritis
Tendonitis
Skin condition(s)
Cardiovascular or circulation condition(s)
Diabetes
Varicose veins
Fibromyalgia
Recent physical trauma
Recent emotional trauma
Depression
Anxiety
PTSD
TMJ
Sleep disturbances
Please describe the conditions you checked:
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I understand, as massage therapy is both a medical and holistic healthcare profession, and in order to receive optimum treatment, the importance of my full disclosure. By entering my electronic signature below, I agree that all the information presented herein is comprehensively accurate to the best of my current knowledge.
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About
Services
Wild Wanderings
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Class Intake Form
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