Serenity Therapeutic Massage

Intake Form

Name(*)
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Today's Date(*)
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E-mail(*)
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Phone Number(*)
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Birth Date
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Address
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City
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State
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Zip Code
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Referred By (optional)
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What is your primary goal for massage therapy?
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What type of work do you do?
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Please explain any recent (within the past 3 months) issues with soreness, pain, stiffness, or decreased mobility:
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Please explain any chronic issues (issues lasting more than 3 months):
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Do you have any areas that should not be massaged? (Ex. Injured, open wounds, bruises, ticklish)
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Please list any recent or lingering injuries, surgeries, or major illnesses:
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Are you currently under the care of a physician? Please list name of physician and reason:
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Please list any medications, supplements, or herbs you are currently taking and any side effects:
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Are you allergic or sensitive to any scents, oils, or lotions?
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Do you currently have: (check all that apply)
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How far along?
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Please describe:
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Intake Agreement(*)
You must agree to this statement in order to receive a massage.

(*)

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