New Client Intake Form — Becky Bartells CMT
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217 South High Street, Suite 201
Harrisonburg, VA, 22802
5406070932
Massage Therapy
Your Custom Text Here
Home
About
About Me
Benefits of Massage
Services & Rates
Gift Certificates
Forms
New Client Intake Form
Cancellation Policy
Contact
Name
*
First Name
Last Name
Email
*
Phone
*
(###)
###
####
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Date of Birth
*
MM
DD
YYYY
Occupation
*
Emergency Contact
*
Emergency Contact Phone
*
(###)
###
####
Date of Initial visit
*
The following information will be used to plan safe and effective sessions. Please answer to the best of your knowledge.
MM
DD
YYYY
Have you ever had a professional massage?
*
Yes
No
Have you ever had Fascial Counterstrain?
*
Yes
No
Do you have any difficulty lying on your front, back or side?
*
Yes
No
Do you sit for long hours at a workstation, computer or driving?
*
Yes
No
If yes, please describe:
Do you perform any repetitive movement in your work, sports or hobbies?
*
Yes
No
If yes, please describe:
Are there areas in your body with tension, stiffness, pain or other discomfort?
*
Yes
No
If yes, please explain:
Medical History
*
Please check any condition listed below that applies to you:
contagious skin disease
open sores or wounds
easy bruising
recent accident, injury or surgery
artificial joint
allergies/sensitivities
heart condition
high or low blood pressure
digestive dysfunction (GERD, IBD, IBS...)
circulatory disorder
atherosclerosis
carpel tunnel syndrom
thoracic outlet syndrome
phlebitis
deep vein thrombosis/blood clots
joint disorder/ RA/ osteoarthritis/ tendonitis
osteoporosis
epilepsy
headaches/ migraines/ cluster headaches
cancer
diabetes
decreased sensation
back/ neck problems
TMJ disorder
medial or lateral epicondylitis (tennis or golfer's elbow)
pregnancy
not applicable
Please explain any conditions marked above:
Is there anything else about your health history that you feel may be relevant to your treatment, including injuries/ surgeries/ accidents from long ago.
Thank you!
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