Intake form - English - Moonflower Massage & Wellness, LLC

Prior to your first appointment, please completely fill this form to the best of your knowledge. Much of this information is required by law as part of your medical records (and must be updated yearly), other sections help us build you a customized service. If you have questions, feel free to contact us.

Name:*

Date of birth:*

Gender:

Address:*

Phone:*

Email address:*

Referred by (how'd you hear about us)*

Emergency contact (name and phone):*

Physician/ health-care provider (name and phone):

If you have received professional bodywork before, how recently?

What types of massage/bodywork do you prefer?

What kind of pressure do you prefer?*

Light

Moderate

Firm

Unsure

What are your goals/expected outcomes for receiving massage/bodywork?*

List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):*

Do these symptoms interfere with your activities of daily living (ie. sleep, exercise, work, childcare)? If yes, explain.*

List the medications you currently take (write NA if none):*

Do you have any of the following?*

Are you pregnant?*

Yes

No

Have you had any injuries or surgeries in the past that may influence today’s treatment? Please include ANY in the past 2 years regardless.*

Select any of the following health conditions that you currently have (If you are unsure, please ask. Please answer honestly, as massage may not be indicated for some conditions):*

Please indicate conditions that you have. You may give details in the comments at the end of this form.*

Allergies (ie. nuts, scents):*

Other medical conditions:

Additional comments:

I consent to massage therapy treatment by the licensed massage therapists of Moonflower Massage & Wellness, LLC. *

Check the box if true

Write your full name below for signature:*

Enter today's date:*

Write your full name below for signature (in case of a minor - under 18):

Enter today's date (in case of a minor - under 18):