Wellsport Bodyworks
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Client Intake Form
Name
*
Address
*
City/State
*
Zip Code
*
Email Address
*
Home Phone
*
Work Phone
Occupation
Date of Birth (month/day/year)
Have you ever had professional body work/massage?
Yes
No
What are your intentions for this session?
Primary area of complaint?
How did this develop?
What makes it worse/better?
Describe your activities at work/home.
What are your short term and/or long-term goals regarding your body?
How do you feel about your general health?
Please check if you wear:
Contact lenses
Dentures
Hair piece/wig
Doctor’s name(s) and phone number(s)
Have you had any recent injuries, surgeries, or hospitalizations?
Are you taking any over the counter prescriptions, medications or supplements?
Do you follow a special diet?
Please check any condition(s) that apply to you:
Muscular Injuries/Diseases
Spinal/Skeletal
High/Low Blood Pressure
Blood Clots
Heart Disease
Circulatory
Diabetes
Anxiety
Swelling/Edema
Migraines/Headaches
Neurological
Arthritis
Allergies
Asthma
Cancer
Abdominal Pain
Chest Pain
Infection of any kind
Digestive
Constipation
Dizziness
Menopausal
Skin Problems
Sleeping Problems
Depression/Mental Disorder
Hernia/Rupture
Fatigue
Other Problems
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