Massage Client Intake Form (Page 2 of 4) in pdf

Please a nswer t he f ollowing q uestions:

Y o r N D o y ou w ear c ontact l enses?

Y o r N D o y ou w ear d entures?

Y o r N H ave y ou h ad e xtensive d ental w ork ( braces, c rowns, e tc.) _ ________________________________

_ _______________________________________________________________________________

Y o r N D o y ou h ave a ny a llergies? I f y es, p lease l ist t hem._______________________________________

_ _______________________________________________________________________________

Y o r N D o y ou h ave a rthritis? W hat t ype a nd w here? _ __________________________________________

_ ________________________________________________________________________________

Y o r N D o y ou h ave a ny h eart p roblems? _ ____________________________________________________

_ _______________________________________________________________________________

Y o r N D o y ou h ave a ny c irculatory p roblems? A ny t ingling o r n umbness? _ __________________________

_ _______________________________________________________________________________

Y o r N D o y ou h ave a ny s pinal p roblems? _ ___________________________________________________

_ _______________________________________________________________________________

Y o r N D o y ou h ave b one o r j oint p roblems? B one l oss? P ain o r l imited m ovement i n j oints? T MJ? _ ____

_ _________________________________________________________________________________

Y o r N D o y ou h ave a ny r espiratory p roblems? _ _______________________________________________

_ ________________________________________________________________________________

Y o r N D o y ou h ave a ny d igestion o r e limination p roblems? _ ____________________________________

_ ________________________________________________________________________________

Y o r N D o y ou h ave a ny t rouble s leeping o r f eelings o f t iredness? _ ________________________________

_ _______________________________________________________________________________

Y o r N D o y ou h ave a ny h earing p roblems? R inging i n t he e ars? _ _________________________________

_ ________________________________________________________________________________

Y o r N A re y ou p resently p regnant? H ow f ar a long? A ny c omplications? _ __________________________

_ _______________________________________________________________________________

Y o r N H ave y ou h ad a ny s urgery? H ow r ecently? C omplications? _ _______________________________

_ _______________________________________________________________________________

Y o r N D o y ou h ave v aricose v eins o r b lood c lots? P lease i ndicate w here. _ __________________________

_ _______________________________________________________________________________

Y o r N D o y ou h ave a ny s kin p roblems, d iseases, o r o pen s ores? W here: _ __________________________

_ _______________________________________________________________________________

Y o r N D o y ou t ake a ny p rescribed m edications? P lease l ist n ame a nd p urpose: _ ____________________

_ _______________________________________________________________________________

Y o r N D o y ou t ake a ny s upplements o r h erbs? P lease l ist n ame a nd p urpose: _ ______________________

_ ________________________________________________________________________________

Y o r N D o y ou e xercise o r p lay s ports o n a r egular b asis? P lease d escribe: _ _________________________

_ ________________________________________________________________________________

Y o r N A re y ou r eceiving a ny o ther c omplementary c are c urrently ( chiropractor, n aturopathic,

a cupuncture, e tc.) I f s o, p lease d escribe. _ _______________________________________________

_ ________________________________________________________________________________

Y o r N D o y ou h ave a ny o ther p hysical o r m ental c ondition o f w hich I s hould b e a ware b efore s tarting t his

S ession? _ ________________________________________________________________________

Massage Client Intake Form Page 2