— Exodus 12:2—

“THIS MONTH SHALL BE THE BEGINNING OF MONTHS FOR YOU”

CLIENT INTAKE FORM

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Name *

First

Last

DOB *

Address *

Email *

City *

State *

Zip Code *

1. What is your primary goal for this massage? (Please check all that apply) *

• Relaxation, stress reduction
• Relieve muscle tension, specify area __________________________________
• General Health and well being
• Other, please verify____________________________________________________

2. Have you had any illnesses, accidents, or injury recently? If so, please explain briefly *

3. Are you experiencing any of he following today? (Check all that apply) *

• Pain or Soreness
• Numbness or Tingling
• Stiffness
• Dizziness
• Nausea
• Swelling

4. Do you have allergies, especiallly to oils, lotions, peanuts: *YesNo

5. For WOMEN- Are you pregnant? *YesNo

6. Have you taken any medications today?YesNo

If so, please list

I have answered the above questions to the best of my ability . I acknowledge that massage therapy does not include medical problems. I give my consent for the massage session. Please (type) sign and date below *

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