Body Work - Intake Form Name * First Name Last Name Email * Phone * (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Occupation * Primary Physician Emergency Contact * Are You taking any medications? If Yes Please list their names: * YES NO Medications Name Are You currently pregnant? YES NO How far are you along? Do You suffer from chronic pain? YES NO If yes, please explain. What makes it better or worst? Have you had any orthopaedic injuries? YES NO If yes, please list: Please indicate if any of the following that apply to you: Cancer Headaches/Migraines Arthritis Diabetes Joint Replacement(s) High/Low Blood Pressure Neuropathy Fibromyalgia Stroke Heart Attack Kidney Dysfunction Blood clots Numbness Sprains or Strains Have you had any professional body work before? YES NO Do you have any allergies or sensitivities? YES NO Please explain: What are your goals for this treatment session? Cancellation Policy: Please give 24 hour notice to cancel an appointment so that I may have time to fill that space. If 24 hour notice is not given I reserve the right to ask for a deposit to book your next appointment. Thank you for respecting my time. “I understand that the Therapeutic Body/Licensed Massage Therapist does not diagnose illness, disease, or any other physical or mental disorder. The therapist does not prescribe medical treatment or pharmaceuticals, nor is massage/body work is a substitute for medical examination or diagnosis and it is recommended that I see a physician for any physical ailment that I may have. I have stated all of my known medical conditions and take it upon myself to keep the therapist updated on any changes.” By signing below you agree to the following, I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time. * Date * MM DD YYYY * Thank you!