Confidential Health Intake Form Name *FirstLastContact PhoneEmail *Address *Birthdate *How did you hear about us?How are you feeling today?Have you ever received a professional massage before?If Yes, how long ago?What is your goal for today's treatment?What level of pressure do you prefer?Light MediumDeepDo any areas require special attention today?Are there any areas you would like avoided today?Are you allergic to any creams, lotions, or oils?What is your main work activity StandingSittingDrivingLiftingRepetitive MotionsWhat physical activities to participate in regularly?Are you currently under the care of a physician?YesNoIf Yes, please explain.Please list any current medications:List any previous auto accidents/ major injuries / surgeries:Have you ever been diagnosed with cancer?YesNoIf Yes, what type and when?Have you ever had a sports injury?YesNoIf Yes, what type and when?What movements and activities are limited and where?What other treatments are you receiving and by whom?Medical History InformationHeadachesInflammationCarpal TunnelJaw Pain / Teeth GrindingAthlete's FootPlantar WartsDepressionAnxietySleep Difficulties FibromyalgiaChronic PainMuscle / Joint PainNumbness / TinglingSprains / StrainsStent / ShuntScoliosisArthritisTendonitisHerniated DiskVaricose VeinsBlood ClotsHigh / Low Blood PressureDiabetesMultiple SclerosisCancer / TumorsInfectious DiseaseContagious Skin DisordersOpen WoundsPregnant Yes NoIf Yes, what trimesterBreast FeedingYesNoBreast ImplantsYesNoIf Yes, when? Reconstructive or Aesthetic?RemarksTo comply with informed consent I will discuss the following with you prior to your treatment: 1. What to expect from your entire treatment 2. Proposed treatment plan and goal 3. Any contraindications or precautions for massage Please take a moment to carefully read the following information and sign where indicated. I understand that the massage/bodywork I receive at ReAwake is provided for basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session I will immediately inform the practitioner so that the pressure and or/ strokes may be adjusted to my level of comfort. I further understand that massage/bodywork should not be construed as a substitute for an examination, diagnosis or treatment of disease/injuries. I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there should be no liability on the practitioner’s part should I forget to do so. I also understand that any illicit or sexually suggestive remarks or advances will result in termination of the session, and I will be responsible for payment of the scheduled session. I agree and adhere to ReAwake’s cancellation policy and will be responsible for charges if I fail to provide 24 hour notice if I cancel or change my appointment. The parties agree that this document may be electronically signed. Electronic signatures appearing on this agreement are the same as handwritten signatures for the purpose of validity, enforceability, and admissibility.Name *FirstLastToday's Date *NameSubmit
