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:

Wellsport Bodyworks