intake form Please fill the form below and we will get back to you soon. Name * First Name Last Name Email * Home Phone Mobile Phone Address Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth MM DD YYYY Refered by Emergency Contact Name First Name Last Name Emergency Phone Date of Initial Visit MM DD YYYY How would you rate your general health? Excellent Good Fair Poor Have you had a professional massage before? Yes Date of last treatment Have you had a professional massage before? No List current medications & the conditions they are treating List any major accidents or surgeries (including dates) Please tell us about any allergies or hypersensitivities Reason for initial visit HEAD NECK Headaches / migraines Ringing in ears Vision problems Vertigo / dizziness Hearing loss Vision loss RESPIRATORY Asthma Chronic cough Emphysema Frequent colds Family history of respiratory difficulties Shortness of breath Bronchitis Sinusitis Smoker NERVOUS SYSTEM Sensory loss / change Sciatica Seizures Numbness / tingling Epilepsy Multiple sclerosis MUSCULOSKELETAL SYSTEM Arthritis Osteoporosis Bursitis Pins / plates / wires / artificial joint Family history of arthritis Tendonitis Jaw pain (TMJ) REPRODUCTIVE Pregnant Gynecological problems Given birth CARDIOVASCULAR High blood pressure Heart attack Heart disease Phlebitis / varicose veins Hemophilia Chronic congestive heart failure Family history of cardiovascular problems Low blood pressure Stroke Poor circulation Pacemaker SKIN & INFECTIONS Hepatitis Herpes Lyme disease HIV / AIDS Tuberculosis Infectious skin conditions OTHER CONDITIONS Cancer Unexplained weight loss Fibromyalgia Depression Psychiatric disorder Diabetes Digestive conditions Chronic fatigue syndrome Anxiety Other conditions It is my choice to receive holistic treatments. I am aware of the benefits and risks of massage and give my consent for massage and/or BodyTalk. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that holistic treatments are not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status. I understand that my personal health information will be collected. I understand that all information that I provide will be kept confidential unless required by law. I understand and consent that my medical information may be shared by the various care providers involved in my care and treatment. I understand that my treatments are not covered by extended health care plans and are my sole responsibility. Signature Date Thank you!