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Massage Intake Form
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Medical Information
Are you taking any medications?
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NO
YES
If YES, Please list name and use
Are you currently pregnant?
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NO
YES
If YES, how far along?
Any high risk factors?
Do you suffer from chronic pain?
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NO
YES
If YES, Please explain
What makes it better?
What makes it worse?
Have you had any orthopedic injuries?
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NO
YES
If yes, please list
Please indicate any of the following that apply to you.
Cancer
Headaches/Migraines
Arthritis
Diabetes
Joint Replacement(s)
High/Low Blood Pressure ☐ Neuropathy
Fibromyalgia
Stroke
Heart Attack
Kidney Dysfunction
Blood Clots
Numbness
Sprains or Strains
Explain any conditions you have marked above
Massage Information
Have you had a professional massage before?
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NO
YES
What type of massage are you seeking?
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Relaxation
Therapeutic/Deep Tissue
What pressure do you prefer?
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Light
Medium
Deep
Do you have any allergies or sensitivities?
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NO
YES
Please Explain
Are there any areas (feet, face, abdomen, etc.) you do not want massaged?
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NO
YES
If YES, Please Explain
What are your goals for this treatment session?
Please explain any areas of discomfort
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