Client Intake Form Name* First Last Today's Date* MM slash DD slash YYYY Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone*Email* Date of Birth* Emergency Contact Name:* Emergency Contact Phone:* Billing Insurance?* Yes No Referred by: Insurance Provider: Policy #? Group #? The following information will be used to help plan safe and effective massage sessions. Please answer the questions to the best of your knowledge.MASSAGE HISTORYHave you received a professional massage before?* Yes No How often? Do you have any goals in mind for this massage session?What is your preferred pressure? Light Medium Firm Do you have any difficulty lying on your front, back or side? Do you have any allergies to oils, lotions or creams? Yes No Would you like to use an CBD cream/salve on areas of concern today?(an up-charge of $5 will apply to hourly rates) Yes No Please describe any areas you would like me to focus on:HEALTH HISTORYDo you sit for long hours at work, a computer or driving? Yes No Do you perform any repetitive movements in your work, sport or hobby? Yes No If yes, please explain:On a scale of 1-10, how would you describe your level of stress? Do you feel stress affects your health? Yes No Are you under the care of a physician for any reason? Yes No If yes, please explain:Have you had any major traumas/surgeries? Yes No If yes, please explain:Do you have any medical conditions I should know about? Yes No If yes, please explain:Is there anything else you think would be useful for me to know to plan a safe and effective massage?CAPTCHAEmailThis field is for validation purposes and should be left unchanged. Δ Michelle Ditter, LMTFlourish Massage Wellness
