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Health Intake Form for Initial Consultation

 

Personal Information for Initial Consultation

First Name
Last Name
Date of Birth
Sex Male Female
Height
Weight

Please provide the following contact information: 

Work Phone or  
Home or Cell Phone
E-mail

Which Session type are you requesting:

How often do you receive massage:

I have never received a massage
A few times a year
About once a month
Once a week or more

 

If interested in learning a bit about astrology, please provide the next 3 fields.  I enjoy doing this!

Complete Date of Birth        
Place of Birth: City & State. 
Time of Birth - if known        

 

Select any of the following options that apply:

I am allergic to peanuts of other nuts
I have other allergies
 I have skin irritations
I have arthritis and/or joint disorders
I have high blood pressure and/or heart problems
I have varicose veins and/or blood clots
 I have spinal problems
 I have frequent headaches
 I am currently under a doctor's care
I have had recent injuries and/or broken bones
 I have had recent surgery

Do you smoke?

Yes
No

List any areas of pain, stress, or discomfort as well as medical conditions - along with ALL medications.   If you are scheduling massage, please list any areas of the body that needs to be avoided and indicate why. 


What physical activities or hobbies keep you engaged?

Have you received energy work before? What type if so:

What do you do for a living? What would you enjoy doing?

What do you do to develop yourself spiritually and/or emotionally?

How do you hope to benefit from my services?

If not in the DFW area, please indicate city location.  Alsom provide any comments and/or additional information here:

If seeking Massage, what type of draping do you prefer?

How will you pay?  Please note that we do not accept insurance at this time.

How did you find my website?

Which session type interests you at present?  For how long?  And when is best?

AGREEMENT:

By submitting this form, I agree and acknowledge to the following:  (Form Submission is the same as my electronic signature.)

I understand that my session begins and ends at a certain time and that my being late does not extend my time.  

I am subject to a 100% fee if I do not show up to my scheduled appointment.

I understand that my therapist provides exactly what is described on the website, and that I have no other expectations.

I understand that fees are for services as advertised only.

I understand that draping is required unless agreed to by both myself and the therapist.  I have indicated my draping preference above.

I understand that breast massage is not performed without written consent.  - ** intended for females only.

For Massage, if I am uncomfortable for any reason, I will ask for the massage to cease immediately.

I will turn off all electronic devices while in the studio.

I will make my therapist aware of any and all electronic devices.

I have listed all of my medical conditions on this form and will update my information should any new conditions arise prior to this session or any future sessions.

 

                     
Revised: 12/19/10

 

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