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MASSAGE INTAKE

NEW CUSTOMERS: Please fill out the following form prior to your first appointment.

INJURIES / SURGERIES
INJURIES: Are you sufferinng or in pain?
SURGERIES: Have you had surgery in the last 12 months?
Do you take meds for this?
ILLNESS/ MEDICAL HISTORY
Arthritis / Joint Problems
Circulation Problems
High Blood Pressure
Rheumatic Fever
Asthma
CollegenVasular Diseae (lupus)
HIV / AIDS
Stroke
Aneurysm
Convulsions/ Epilepsy
Kidney Infections / Stones
Thyroid Disease
Back Problems
Deep Vein Thrombosis
Liver Disease
Tuberculosis
Bowel Problems
Depression, Anxiety Seizures
Migraine Headaches
Broken Bones
Diabetes
Osteoporosis
Cancer (Any Kind)
Heart Attack / Problems
Pneumonia

Thanks for submitting!

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