Health Intake FormThe more detailed information you can provide us, the better we can customize your session. Name * First Name Last Name Email * Phone * (###) ### #### Emergency Contact * First Name Last Name Emergency Contact Phone * (###) ### #### Date of Birth * Your pronouns: Occupation * Who can we thank for referring you to us? * Have you had professional massage before? * No this is my first one Only a few times Yes, yearly Yes, monthly What is your primary reason for scheduling this massage? * Hydration: how many ounces of water to you drink per day? Current physical activity level? Sports/hobbies past or present? Please list any medications/supplements/vitamins you take. Please list any allergies/sensitivities you have (food, medicine, environment, scents, etc.) Are you working with a provider (including pregnancy)? If so, who? Please check any of the following boxes that apply to you, past or present. * Heart/Circulatory Issues Cancer/tumor High/Low BP Blood Clotting Disorder Mental Health Issues STI/STD Insomnia TMJ Breathing/Sinus Issues Arthritis Headaches/Migraines Numbness/Tingling Fibromyalgia Diabetes Carpal Tunnel Skin Condition Chronic Pain GI Issues Stroke Seizures Surgery Injury Other None of the above Please elaborate on any checked conditions above. If you have a uterus, please check any boxes that apply to you, past or present. Menstrual Issues Fibroids PCOS Fertility Issues Miscarriage History Intentional Miscarriage Ectopic/Molar Pregnancy Late Term Loss/ Stillbirth Cesarean VBAC (vaginal birth after cesarean) Pelvic Organ Surgery Currently Pregnant (provide EDD below) Currently Postpartum (12mo or less) Currently Breast/Chest Feeding or Pumping Previous Children (list birthdays below) Pelvic Floor Concerns Please elaborate on any checked boxes above. If pregnant, please check any boxes that apply. Bleeding Hyperemesis Gravidarum History of preterm labor Headache/Migraine Swelling Vision changes High/Low BP Marginal/Partial/Complete Placenta Previa Gestational Diabetes Twins/Multiples Is there any other information about yourself you would like to share? Thank you!
