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Mobile Massage
Contact
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+1 (516) 988-5160
1195 Bushwick Ave, Brooklyn, New York
Intake Form
Name
Phone (Day)
Phone (Night)
Email
Date of Birth
Address
City/State/Zip
Occupation
Employer
Primary Physician
Emergency Contact Information
Name
Relationship
Phone
Are you taking any medication
Yes
No
If yes, please list name and use?
Are you currently pregnant?
Yes
No
If yes, how far along?
Any high risk factors?
Do you suffer from chronicpain?
Yes
No
If yes, please explain
What makes it better?
What makes it worse?
Have you had any orthopedic injuries?
Yes
No
If yes, please list:
Please indicate any of the following that apply to you.
Cancer
Fibromyalgia
Headaches/Migraines
Stroke
Arthritis
Heart Attack
Diabetes
Kidney Dysfunction
Joint Replacement(s)
Blood Clots
High/Low Blood Pressure
Numbness
Neuropathy
Sprains or Strains
Explain any conditions you have marked above:
What type of massage are you seeking?
Relaxation
Therapeutic/Deep Tissue
Other
If other, please specify:
Have you had a professional massage before?
Yes
No
What pressure do you prefer?
Light
Medium
Deep
Do you have any allergies or sensitivities?
Yes
No
Please explain:
Are there any areas (feet, face, abdomen, etc.) you do not want massaged?
Yes
No
Please explain:
What are your goals for this treatment session?
Please indicate the areas on your body that are causing you discomfort:
I hereby confirm that I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time.
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