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New Client Form
Please fill out the following health intake form.
First name
Last name
Date of Birth
Email
Phone
Address
Emergency Contact
State
Zip Code
Emergency Contact Phone
Have you received professional massage/bodywork before?
No
Yes
If you answered yes to any question, please elaborate on type and how recent:
Have you been hospitalized in the last 12 months?
No
Yes
Are you suffering from a medical condition, illness, or injury?
No
Yes
List any medical conditions, accidents, surgeries, injuries, and allergies (any of these may influence your treatment):
List and prioritize your current symptoms/issues (stress, pain, stiffness, tingling, swelling, etc.):
Do these symptoms interfere with your activities of daily living (sleep, exercise, work, childcare, etc.)?
No
Yes
If you answered yes to the above question, please explain:
Initials
I declare that the info I’ve provided is accurate & complete
Submit
Thanks for submitting!
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