Client Intake Form - Farr Out Wellness

Please take your time and fill this out to the best of your ability. The information on this form is critical to helping develop a safe and effective plan of action for your session.

This form is required for ALL first-time clients. Returning clients are asked to look it over and make any necessary updates. You may also choose to fill this form out in person (on paper) before your first session if you prefer.

Name*

Birth Date*

Address (Street/City/Zip)*

Phone*

Occupation*

Referred by*

Emergency Contact (Name & Phone)*

Have you ever experienced a professional massage or bodywork session? If yes, how recently? If not, type "N/A".*

Have you received care from:*

What are your massage/bodywork goals?*

What kind of pressure to you prefer?*

Light

Medium

Deep

I'm not sure.

Is your stress level:*

Low

Moderate

High

Please look over this list and check all that apply:*

If you checked any disorders or diseases above, please explain. Include dates, affected regions, and any symptoms of concern. If not, type "N/A".*

Do you wear:*

In which part(s) do you experience stress? (Check all that apply.)*

Are you sensitive to touch in any areas? If yes, explain. If not, type "N/A".*

Do you have any food or nut allergies, especially coconut? If yes, please explain. If not, type "N/A".*

Have you had any of the following regarding your current condition?*

What relieves your pain?*

What aggravates your pain?*

List any injuries that occurred within the past 2 years (broken bones, torn ligaments, auto accident, etc):*

List any surgeries, including what procedure(s) and date(s):*

Please list all medications you currently take. Include over-the-counter medications as well as vitamins/herbs.*

Is there anything else about your health history that you think would be useful for your practitioner to know to plan a safe and effective session for you? Please explain.*