Massage Therapy Intake Form

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Massage Therapy Intake Form
Name ______________________________________
DOB _______________
Address___________________________________________________________________________________
City______________________ State_________
Zip Code______________
Phone ____________________________
Email_________________________________________________
Emergency Contact Name & Number ___________________________________________________________
Please Indicate Areas of Pain or Discomfort:
Are you currently pregnant?
Yes or
No
If yes, how far along are you?____________________________
Please list any allergies you may have, including fragrances: _________________________________________
__________________________________________________________________________________________
Please review and check the conditions below that have affected your health either recently or in the past:
___ Arthritis
___Depression
___ Cancer
___ TMJ
___ Diabetes
___ Headaches/Migraines
___ High B.P.
___ Bruise Easily
___ Blood Clots
___ Heart Conditions
___ Scoliosis
___ AIDS/HIV
___ Eczema/Psoriasis
___ Seizures
___ Whiplash
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