New Patient Massage
Intake Form
Step
1
of
2
- CONTACT DETAILS
0%
CONTACT DETAILS
Full Name
*
Date Of Birth
*
MM slash DD slash YYYY
Telephone
Occupation
Email
*
How did you hear about me?
GENERAL HEALTH / MEDICAL HISTORY / LIFESTYLE
Do you have any injuries and/or complaints at present?
Yes
No
If Yes, please indicate
Have you had any operations in the last 5 years?
Yes
No
If Yes, please indicate including year
Do you, or have you ever suffered from any of the following conditions:
Asthma
Epilepsy
Stroke
Heart Problems
Osteoporosis
Cancer
Varicose Veins
Hypo / Hyper Thyroid
Migraine
Headache
High Blood Pressure
Low Blood Pressure
Do you take natural and/or pharmaceutical medication?
Yes
No
If Yes, please list
Are your bowel movements regular?
Yes
No
Pregnant and/or lactating?
Yes
No
N/A
Menstrual cycle regular?
Yes
No
N/A
Do you have any allergies, including any essential oils?
Yes
No
If Yes, please list
Do you smoke?
Yes
No
If yes, how much?
Do you drink tea/coffee?
Yes
No
If yes, how much?
Do you drink alcohol?
Yes
No
If yes, how much?
Water per day
Which best describes your diet?
Heavy meat consumption
Fast Food
Rich Foods
Lots of dairy & desserts
Vegetarian or Vegan
Combination
Do you exercise regularly?
Yes
No
if Yes, please list hours per week and what type
Do you suffer unusually from any of the following:
Fatigue
Stress
Anxiety
Phobias
Depression
Postnatal depression
Nervousness
Anger
Menopause
Addiction
Mood swings
Insomnia
Anorexia
PMS
Are there any other health concerns that you want brought to my attention?
How often do you currently get massages?
What type
What would you like to experience today?
Pin It on Pinterest
Share This
Facebook
Twitter
Pinterest
LinkedIn
StumbleUpon
Like
