Confidential Health Intake Form Your First NameField is required!Field is required!Your Last NameField is required!Field is required!Your E-mail AddressField is required!Field is required!Your Mobile Phone NumberField is required!Field is required!Your AddressField is required!Field is required!CityField is required!Field is required!- select a state -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonMarylandMassachusettsMichiganMinnesotaMississippiMissouriPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming- select a state -Field is required!Field is required!ZipcodeField is required!Field is required!Enter your D.O.B.Field is required!Field is required!How Did You Hear About Us?Field is required!Field is required!How Are You Feeling Today?Field is required!Field is required!Have you ever received a massage before?YesNoField is required!Field is required!If yes, how long ago?Field is required!Field is required!What are your goals for today's treatment?Field is required!Field is required!What level of pressure do you prefer?LightMediumDeepField is required!Field is required!Do any areas require special attention today?Field is required!Field is required!Are you allergic to any creams, oils, or lotions?Field is required!Field is required!What best describes your main work activity?StandingSittingDrivingLiftingRepetitive MotionsField is required!Field is required!What physical activities do you participate in regularly?Field is required!Field is required!Are you currently under the care of a physician?YesNoField is required!Field is required!If yes, please explainField is required!Field is required!Please list any current medications:Field is required!Field is required!Have you ever been diagnosed with cancer?YesNoField is required!Field is required!If yes, what type and when?Field is required!Field is required!Have you ever had a sports injury?YesNoField is required!Field is required!If yes, what type and when?Field is required!Field is required!What other treatments are you receiving, and by whom?Field is required!Field is required!What movements and activities are limited, and where?Field is required!Field is required!Medical History ( Check any that apply )HeadachesInflammationCarpal TunnelJaw Pain / Teeth GrindingAthlete's FootPlantar WartsDepressionAnxietySleep DifficultiesFibromyalgiaChronic PainMuscle / Joint PainNumbness / TinglingSprains / StrainsStent / ShuntScoliosisArthritisTendonitisHerniated DiskVaricose VeinsBlood ClotsHigh / Low Blood PressureDiabetesMultiple SclerosisCancer / TumorsInfectious DiseaseContagious Skin DisordersOpen WoundsField is required!Field is required!Are you currently pregnant?YesNoField is required!Field is required!If yes, what trimester?Field is required!Field is required!Are you currently breast feeding?YesNoField is required!Field is required!Have you previously had breast implants?YesNoField is required!Field is required!If yes, when? Reconstructive or aesthetic?Field is required!Field is required!Is there anything else you'd like us to know?Field is required!Field is required!Please take a moment to carefully read the following information and sign where indicated.I understand that the massage/bodywork I receive at ReAwaken Spa 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 ReAwaken Spa’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.Field is required!Field is required!Submit
