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Embrace Metta Massage Intake Form

Please print clearly and complete all the responses to the best of your knowledge. All information will be strictly confidential.

Name:

Email:

Address:

Postal Code:

Home/Business Phone:

Cell Phone:

D.O.B. (D/M/Y):

Age:

Sex: M/F Emergency Contact:

Phone:

How did you hear about us?

Are you presently under the care of a medical doctor/health practitioner?

Y/N Primary health concern:

Are you on any form of medication?

Y/N

List:

Do you have any restrictions in movement? Y/N Are there any stretches or yoga postures which may be harmful?

Are you involved in regular physical activity? Y/N What type?

Please indicate which of the following apply to you:

__Aids __Allergies/sinus __Aortic aneurysm __Arteriosclerosis __Arthritis __Cancer __Cervical spine problems __Clicking/popping ears/jaw __Constipation __Diarrhea __Difficult digestion __Dislocation

__Fractures __Headaches __Heart disease __Hemophilia __Hernia __Hepatitis A/B/C __High blood pressure __Joint problems __Kidney/bladder __Liver/gallbladder __Menstrual problems __Open wounds/cuts

__Osteoporosis __Phlebitis (DVT) __Pregnancy – Due Date: __Recent surgery __Rheumatoid arthritis __Skin disease __Stroke __Tooth/jaw pain __Varicose veins __Other: List below

______

Musculoskeletal Please indicate areas of pain by shading in affected areas.

Consent for Thai Massage:

It is understood that the purpose of Thai Massage is for relaxation and that it is not meant to diagnose or treat any illness, disease, or any other physical or mental disorder, injury, or condition. I have informed my practitioner about my state of health and have transmitted any recommendations and restrictions on the part of my medical doctor or therapist insofar as massage is concerned.

Client’s signature:

Date:

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