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Intake form - English

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 reach out.

Name:

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Date of birth:

Gender:

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Phone:

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Email address:

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Referred by (how'd you hear about us)

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Emergency contact (name and phone):

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

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If you have received professional bodywork before, how recently?

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What kind of pressure do you prefer?

Light

Moderate

Firm

Unsure

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Do you have any of the following?

Dentures

Contacts

Wig/hairpiece/extensions

Aesthetic Implants (ie. breast implants, plastic surgery)

Medical Implants (ie. ports, pacemaker)

NONE

Are you pregnant?

Yes

No

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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):

Blood clots

Infections

Congestive heart failure

Contagious diseases

Pitting edema

NONE

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

Bruise easily

Numbness/Tingling/Stabbing pains

Sensitive to touch/pressure

Swelling (ie. in joints)

Varicose veins

Arthritis (ie. Rheumatoid, osteoarthritis)

Osteoporosis

Spinal Disc issues (ie. herniation, bulging, Degenerative disc disease)

Scoliosis

Broken bones (last 2 years)

NONE

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

High blood pressure

Low blood pressure

Diabetes - Type I

Diabetes - Type II

Cardiac/circulatory problems (ie. stroke, heart attack)

Epilepsy/seizures

Headaches/migraines

Dizziness/ringing in ears

Shortness of breath/Asthma

NONE

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

Neurological conditions (ie. MS, Parkinson's)

Endocrine/thyroid conditions

Digestive conditions (ie. Crohn's)

Kidney disease/infection

Cancer

NONE

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

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Write your full name below for signature:

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Enter today's date:

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

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