MASSAGE INTAKE FORM | Massage By Cheri

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H O M E
A B O U T
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A P P O I N T M E N T S
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MASSAGE INTAKE

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

First Name

Mobile Phone

Last Name

Home Phone

Date of Birth

Gender

Email

Emergency Contact

How did you hear about us?

Emergency Contact Phone

Who can we thank for referring you?

INJURIES / SURGERIES

INJURIES: Are you sufferinng or in pain?

No

Yes

SURGERIES: Have you had surgery in the last 12 months?

No

Yes

If so, where?

If so, what surgery?

Date of Surgery

How long has this been hurting?

Name of Surgeon

How did it happen? Was it a fall or ther injury?

Surgeon's Phone

Do you take meds for this?

No

Yes

Name of Facility

What are they and dosage?

Facility Phone

Are you on medication? If so, what and dosage?

ILLNESS/ MEDICAL HISTORY

Arthritis / Joint Problems

No

Yes

Circulation Problems

No

Yes

High Blood Pressure

No

Yes

Rheumatic Fever

No

Yes

Asthma

No

Yes

CollegenVasular Diseae (lupus)

No

Yes

HIV / AIDS

No

Yes

Stroke

No

Yes

Aneurysm

No

Yes

Convulsions/ Epilepsy

No

Yes

Kidney Infections / Stones

No

Yes

Thyroid Disease

No

Yes

Back Problems

No

Yes

Deep Vein Thrombosis

No

Yes

Liver Disease

No

Yes

Tuberculosis

No

Yes

Bowel Problems

No

Yes

Depression, Anxiety Seizures

No

Yes

Migraine Headaches

No

Yes

Other Illnesses

Broken Bones

No

Yes

Diabetes

No

Yes

Osteoporosis

No

Yes

Other Illnesses

Cancer (Any Kind)

No

Yes

Heart Attack / Problems

No

Yes

Pneumonia

No

Yes

Other Illnesses

If you answered yes to any question, please elaborate

I declare that the info I’ve provided is accurate & complete

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