aumhaus | bodywork and massage intake form

bodywork and massage intake form

all fields MUST be filled in.

about you

first name

last name

address

city

state / province

postal / zip code

home phone number

email

height

weight

mobile phone number

birthday

body shape

mesomorph

ectomorph

endomorph

EMERGENCY CONTACT

phone number

relationship

general health information

how would you rate your general health?

excellent

good

fair

poor

please list any current medications and the conditions they are treating:

please list any major injuries, accidents or surgeries (including the approx. date):

do you have any previous experience with massage therapy?

yes, my last massage therapy treatment was on

no

reason for visit

primary complaint, cause and location of discomfort:

when did the pain/discomfort start?

how often do you feel pain/discomfort:

constantly

comes and goes suddenly

comes and goes gradually

other

pain intensity:

mild

moderate

severe

health history

general

we like to recognize those people/organizations that refer patients to us. please let us know how you found us:

i hereby state that, to the best of my knowledge, my answers to the above questions are correct. i agree to and consent to assessment and treatment. i understand and consent that my medical information may be shared by the various care providers involved in my treatment.