Glo Massage Intake Form Confidential Information
ADVERTISEMENT
1
2GLO MASSAGE
Intake Form
CONFIDENTIAL INFORMATION
Today’s Date
Name
Date of Birth
Address
City
State
Zip
Phone (home)
(work/cell)
email
Occupation
Height
Weight
Emergency contact name & number
Referred by:
Are you pregnant or trying to become pregnant? ______ If yes, how many weeks: ____ EDD: ____
Are you currently in pain or experiencing any discomfort? If so, please briefly explain:
__________________
Describe any chronic pain/tension
What makes it better?
What makes it worse?
Are you currently under the care of a physician, chiropractor or alternative medicine practitioner? If
yes, what are you being treated for?
Please list any medications (prescription or non-prescription), vitamins and supplements you are
currently taking:
Are you currently receiving any other body or energy therapies?
If yes, what for?
What specific areas would you like for me to focus on or stay away from?
Updated 0411
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business