Client Intake Form

Contact Info:
Covid-19 Symptoms:
Have you had a fever in the last 24 hours of 100 degrees F or above?
Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath?
Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms?
Medical Conditions:
Are you taking any medications?
Are you currently Pregnant?
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Do you suffer from chronic pain?
Have you had any orthopedic injuries?
Please indicate any of the following that apply to you.
Massage Conditions:
Have you ever had a professional massage before?
What type of massage are you seeking?
What type of pressure do you like?
Do you have allergies or skin sensitivities?
Are here any areas (feet, face, abdomen, etc.) you do not want massaged?

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.

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