7 Oaks Bodywork and Massage, LLC
*CONFIDENTIAL* CLIENT INTAKE/HEALTH HISTORY FORM*
Name: _____________________________________ Birth Date:________________________________
Address: _________________________________ City/Zip:_____________________________________
Telephone: (H) _________________Referred by: _____________________________________________
Your occupation:____________________________________
Would you like to receive email communications? Y/ N
Email________________________________________________________________ ________________
*Please answer the following questions by circling Y- (Yes), N- (No).
Y – N Have you ever had a professional massage before? If so, what did you like or dislike?
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Y – N Are you under Chiropractic care? If so, name of doctor? ___________________________
Y – N Have you had any type of surgery? If so, please indicate type of surgery & year performed.
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Y – N Do you have any spinal problems?_________________________________________________________________
Y – N Do you have chronic back pain or muscle tension? (specify areas)
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Y – N Do you have arthritis?
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Y – N Have you suffered any recent injuries?
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Y – N Do you have pain in your legs or arms?
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Y – N Do you experience frequent headaches? If so, how often?
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Y – N Do you take any prescribed medication or any vitamins?
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Y – N Do you have any heart problems? High or low blood pressure?
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Y – N Do you have varicose veins or any blood clots?
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Y – N Do you or have you ever had any type of cancer?
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Y – N Do you have any implants? (i.e. knee, pacemaker etc.)
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Y – N Any allergies or sensitivities, including nuts, creams or lotions?
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Y – N Do you have any skin conditions?(i.e. rashes, warts, fungus etc.)
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Y – N Are there any body regions you do not want massaged (i.e. feet, face)?___________________
Y – N Are you constantly tired?
Y – N Are you pregnant?
Do you have any other conditions I should be aware of? If so, please specify.
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