Jade's Body Work - Give your Stress Wings and let it Fly Away....
  

CLIENT INTAKE FORM
Personal Info
Name
Address
City State Zip
Number
Email
Occupation
Emergency Contact name and number
Massage Experiance
Have you had a professional massage before?
Yes
No
If yes, what types of massage have you had (swedish, shiatsu, deep tissue, etc.)?
How long have you been receiving massage therapy?
What are your goals for treatment?
Current Health
Do you exercise regularly and/or participate in any sports?
yes
no
If yes, what kind of exercise/sports?
Do you perform any repetitive movement in your work, sports or hobby?
Yes
No
If yes, describe.
Do you sit for long hours at a workstation, computer or driving?
Yes
No
If yes, describe
Are you experiencing tension, stiffness, discomfort or pain?
Yes
No
If Yes, describe
Have you recently had an injury, surgery, or areas of inflammation?
Yes
No
If yes, describe
Do you have sensitive skin?
Yes
No
Do you have any allergies to oils, lotions or ointments?
Yes
No
If yes, please explain
List any known allergies
List any medications you are currently taking
Health History
Musculoskeletal
Bone or Joint disease
Tendonitis/Bursitis
Arthritis/Gout
Jaw Pain (TMJ)
Lupus
Spinal Problems
Migraines/Headaches
Osteoporosis
Circulatory
Heart Condition
Phlebitis/Varicose Veins
Blood Clots
High/Low blood Pressure
Blood Clots
High/Low Blood Pressure
Thrombosis/Embolism
Respiratory
Breathing Difficulty/Asthma
Emphysema
AllergiesSinus Problems
Sinus Problems
Nervous System
Shingles
Numbness/Tingling
Pinched Nerve
Chronic Pain
Paralysis
Multiple Sclerosis
Parkinson’s Disease
Reproductive
Pregnant, stage
Ovarian/Menstrual Problems
Prostate
Skin
Allergies
Rashes
Cosmetic Surgery
Athlete’s Foot
Herpes/Cold Sores
Digestive
Irritable Bowel Syndrome
Bladder/Kidney Ailment
Colitis
Crohn’s Disease
Ulcers
Psychological
Anxiety/Stress Syndrome
Depression
Other
Cancer/Tumors
Diabetes
Drug/Alcohol/Tobacco Use
Contact Lenses
Dentures
Hearing Aids
Any other medical condition(s) not listed:
Please explain any of the conditions that you have marked above :
Date form completed



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