Confidential Health Intake Form

Your First Name
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Your Last Name
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Your E-mail Address
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Your Mobile Phone Number
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Your Address
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City
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  • - select a state -
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- select a state -
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Zipcode
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Enter your D.O.B.
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How Did You Hear About Us?
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How Are You Feeling Today?
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Have you ever received a massage before?
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If yes, how long ago?
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What are your goals for today's treatment?
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What level of pressure do you prefer?
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Do any areas require special attention today?
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Are you allergic to any creams, oils, or lotions?
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What best describes your main work activity?
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What physical activities do you participate in regularly?
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Are you currently under the care of a physician?
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If yes, please explain
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Please list any current medications:
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Have you ever been diagnosed with cancer?
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If yes, what type and when?
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Have you ever had a sports injury?
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If yes, what type and when?
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What other treatments are you receiving, and by whom?
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What movements and activities are limited, and where?
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Medical History ( Check any that apply )
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Are you currently pregnant?
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If yes, what trimester?
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Are you currently breast feeding?
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Have you previously had breast implants?
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If yes, when? Reconstructive or aesthetic?
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Is there anything else you'd like us to know?
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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.
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