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ABOUT
THE SPA
ON THE GO
Facials
Massages
Urban Retreat
PARTIES
Adult Spa Parties
Chair Massage Event/Party
CORPORATE
MEMBERSHIP
SHOP
Contact
Contact Us
Directions & Parking
Policies & FAQs
eGifts Cards
Massage Intake Form
pixlgraphx
2020-10-26T15:20:33-04:00
MASSAGE INTAKE FORM
Name:
Address:
City:
State:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip:
Main Telephone:
DOB:
MM slash DD slash YYYY
Referred by:
Emergency Contact:
Email Address:
Please take a moment to carefully read following information and sign where indicated. If you have a specific sympton, massage/bodywork may be contraindicated. A referral from your primary care provider may be required prior to service being provided.
Ocuppation:
Gender:
Female
Male
Are you here for:
Pampering
Pain Management
Healing
Nurturing
Have you ever experienced a professional Massage or Bodywork session?
Yes
No
Do you frequently suffer from stress?
Yes
No
Do you have diabetes?
Yes
No
Do you experience frequent headaches?
Yes
No
Are you pregnat?
Yes
No
Do you suffer from arthritis?
Yes
No
Are you wearing dentures?
Yes
No
Do you have high blood pressure?
Yes
No
If Yes, are you taking medication for this?
Yes
No
Are you suffer from epilepsy or seizures?
Yes
No
Do you suffer from joint swelling?
Yes
No
Do you have varicose vein?
Yes
No
Do you have any contagious disease?
Yes
No
Do you have osteoporosis?
Yes
No
Do you have any allergies?
Yes
No
If Yes, list:
Do you bruise easily?
Yes
No
Have you had any broken bones in the past two years?
Yes
No
Have you been in an accident or suffered any injures in the past two years?
Yes
No
Do you have any tension or soreness in a specific area?
Yes
No
...Where?
Do you have cardiac or circulatory problems?
Yes
No
Do you suffer from back pain?
Yes
No
Do you have numbess or stabbing pains anywhere?
Yes
No
...Where?
Are you sensitive to touch or pressure in any area?
Yes
No
Have you ever had a surgery?
Yes
No
Do you have any other medical conditions or medications we should know about?
Yes
No
If you answer Yes to any of the above questions, please explain as clearly as possible:
Client's Signature:
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