Intake FormNew Clients please take a moment to fill out this intake form. It will help us to orient and optimize our time in session together. Name * First Name Last Name Pronouns Email * Phone (###) ### #### Emergency Contact * Name/Phone # What Brings You To BodySpeaks Wellness? * Goals / Concerns / Intentions? Medical History List any recent surgeries or injuries. List any past surgeries or injuries. List any medications you are currently taking, including herbs and supplements, and why. Any skin allergies or sensitivities? Are you currently pregnant or trying to become pregnant? If you have any medical conditions or side effects from treatment of medical conditions, it is helpful to let me know. Things such as prosthetics, energy level, blood counts, bruising easily, skin affected, nausea, bowel problems, edema/swelling, neuropathy, blood clots, bone density, contagious conditions, etc. may alter the type of work you are able to receive. I am trained to work with these conditions but need to have the information in order to provide the most effective session for you. Touch Intake Have you ever received a professional massage? What was your experience? List any areas of your body that cause you pain or you think need more work than others. List any areas that you prefer not to have worked. Is there anything else in your touch history you would Cathy to know? * Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I further understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. * I agree Understanding all of this, I give my consent to receive care. * By Signing my name below I agree to all of the above. Thank you!
