Client Intake Form Name* First Last Phone*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency Contact Name* First Last Email* Occupation* Date of Birth MM slash DD slash YYYY General HealthRate your level of stress* 5 4 3 2 1 5 = Highest, 1 = LowestList your stress or other stress reduction activitiesDo you wear contact lenses?* Yes No Do you smoke?* Yes No Please list any accidents or surgeries in the last 9 months*Do you have any metal implants, pacemaker or body piercings? Yes No List the medications you are currently takingMassage TherapyHave you ever had a professional massage before? If so, when?*What type of pressure do you prefer?*Is there any area of your body you do not want massaged?*Goal for your massage session Relaxation Pain Relief Stress Reduction Health HistoryCheck all that apply Heart Condition Lymph Edema Herpes/Shingles High Blood Pressure Low Blood Pressure Numbness / Tingling Sinus Problems Allergies Chronic Pain Varicose Veins Rashes Jaw Pain / TMJ Blood Clots Constipation Sprains / Strains Diabetes Gas / Bloating Headaches Arthritis Spasms / Cramps Broken / Fractured Bones Pregnancy Fatigue / Sleep Disorder Depression / Anxiety Cancer Skin CareAre you under the care of a dermatologist* Yes No Do you use Accutane Retin A Renova Adapalene Other prescription skin products Are you currently using any products that contain Glycolic Acid Lactic Acid Hydroxy Acid Vitamin A Do you have any skin sensitivities, allergies, or irritants?By submitting, I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it superseded any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation from treatments received. The treatments I receive here are voluntary and I release this institution and individual therapist from any and all liability and assume full responsibility thereof. For minors under the age of 18, parent or guardian signature constitutes consent.