Client Information - DOC

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Client Information - DOC Powered By Docstoc
					                          Massage Spa Treatment
                          Client Intake form

Name:                                  Today’s Date:

E-mail:                                Birth Date:

Home Number:                           Cell Number:

Address:                               City, State, Zip:

In case of emergency notify:           Telephone Number:

How did you hear about Primal          Referred By (if applicable):
Occupation:                            Work Number:

Are you allergic to any Essential      What Essential oil do you like or
oils?                                  dislike?
     Yes  No
Please List:                           Please List:
Have you ever had a massage?           If applicable what did you like
          Yes  No                    about your previous massages?
If yes, how long has it been?
What kind of work do you prefer?       Do you bruise easily?
  Deep  Medium  Light                   Yes        No
What is your skin type?                Are you comfortable having your
  Oily  Dry  Combination            feet massaged?
                                        Yes       No
Are you comfortable having your        Would you like work done on your
abdomen massaged?                      gluteal muscles?
 Yes  No                               Yes  No
*Abdomen massages are helpful to the   *If you are having low back problems I
digestion process.                     would suggest gluteal work.
                                                                                                                           Over 

~ Please leave a or  to answer yes to any of the following questions, please explain as clearly as possible.

      Do you have diabetes?                                             Do you experience frequent headaches?
       List any complications                                            Have you been in an accident or suffered any
                                                                          Injuries in the past two years?
      Do you have High Blood Pressure?                                  Do you have tension or soreness in a specific area?
      Do you have Arthritis?                                             Please Specify
      Do you wear contact lenses?                                       Have you ever had any surgery? Explain in comments.
      Do you suffer from joint swelling?                                Do you have numbness or stabbing pains?
      Do you have any contagious diseases?                              Do you have cardiac or circulatory problems?
      Do you have osteoporosis?                                         Do you have any malignant tumors?
      Do you have allergies (internal or external)?                    Any allergies to essential oils


I have completed this information to the best of my knowledge. I understand the massage services provided are designed to be a
health aid and are in no way to take the place of a doctor’s care when it is indicated. Information exchanged during any massage
session is educational in nature and is intended to help me become more familiar and conscious of my own health status and is to be
used at my own discretion.

Date:                                       Signature: