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New Client Intake Form

Please fill out the following form before coming in for your session.

First Name

Last Name

Email

Date of Birth

Have you ever received professional massage/bodywork before?

No

Yes

If yes, how often do you get massage/bodywork?

Any alergies to lotions, oils, ointments or fragrance?

Do you have any particular goals in mind for this session?

What types of massage/bodywork do you prefer?

Swedish

Deep Tissue

Thai Massage

Neuromuscular

Sports Massage

Is there any particular area of the body you would like to focus on for this session?

Do you have any area that is difficult to move?

What type of work do you do?

Type of activity of daily living?

Taking any medications?

Have any health condition mentions below?

High/low blood pressure

Shortness of breath, asthma

Neurological (e.g. MS, Parkinsons, chronic pain, fibromialgia)

Epilepsy, seizures

Kidney disease, infection

Dementia/Alzheimer's

Scoliosis

Arthritis (rheumatoid, osteoarrthritis)

Diabetes

Endocrine/thyroid conditions

Cancer

Stroke, heart attack

Vericose veins

Contagious disease

None

I consent for treatment of massage and bodywork theapy. I understand that massage/bodywork should not be contrued as a substitute for medical examination. Massage and bodywork should not be performed during certain medical conditions. I affirm I have stated all my medical conditions as such. I agree to keep the practitioner updated as to any changes in my medical profile.

Thanks for submitting! We look forward in seeing you soon.

© 2019 by Luminous Massage & Bodywork LLC.

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