The Balanced Body

Confidential Intake Form

Balanced Body Spa

Professional Massage & Bodywork

Welcome! Thank you for choosing The Balanced Body Spa.

In order to make your session as productive as possible, please complete the following questions.

Name ____________________________________________Date of Birth (mm/dd/yyyy)_______________

Address __________________________________City____________________State ______Zip _________

Home Phone_____________________ Work________________ Cell & Provider _____________________

Occupation ________________ Who referred you to us? ________________________________________

What is your preference for future appointment confirmations? ----- Text ----- Email ----- Phone call -----
Email address: (Please Print) ______________________________________________________________

Have you had massage before? Yes___No__ If yes, what kind? (Swedish, shiatsu, deep tissue, etc.) ________________________________________________________________________________________

Please review this list and check those conditions that have affected

your health either recently or in the past.

___Arthritis ___Diabetes ___Depression

___Blood Clots ___Diverticulitis ___Broken bones

___Headaches ___Bruise easily ___Heart conditions

___Cancer ___Back problems ___Chronic pain/fatigue

___High Blood Pressure ___Insomnia ___Muscle strain/sprain

___Hep atitis (A,B,C) ___Scoliosis ___Skin conditions

___Fibromyalgia ___Lupus ___HIV/AIDS

___Stroke ___Seizures ___Chemical dependency

___Whiplash ___TMJD ___Surgery______Date

If any of the above needs to be detailed, please do so: __________________________________________

Are you taking any medications? Yes___No___ If yes, please list._________________________________

________________________________________________________________________________________

Do you have any of the following today?

___Skin rash ___Cold/Flu ___Open cuts ___Severe pain ___Injuries/bruises ___Anything contagious

Are you pregnant? Yes___No___ If yes, when are you due? __________________________

(continue on back)

Do you have any allergies to:

___Medications ___Foods (nuts, etc) ___Dust/Pollen/Perfume

Are there any areas that you do not want worked?

___Feet __Scalp ___Other (Please list) _____________________________________

Are you right or left handed? (Circle one.)

Please indicate with an (X) any areas where you are feeling discomfort.

What are your goals for this session?_________________________________________________

The following sometimes occurs during massage. They are normal responses to relaxation. It is ok if you experience any of these during your session.

≈A need to move or change position ≈ heavy sighing or yawning ≈ gurgling stomach

≈ emotional feelings and/or expression ≈ intestinal gas ≈ energy shifts ≈ memories ≈ falling asleep/snoring

Please read the following information, check the boxes, and sign below.

□I understand that massage therapy is not a substitute for medical examination, diagnosis or treatment.

□This is a therapeutic massage. Any sexual remarks or inappropriate behavior will terminate the session, and I will be liable for payment of the scheduled treatment.

□Because massage therapy can be contraindicated for certain medical conditions; I affirm that I have answered all questions about my medical conditions truthfully.

Signature___________________________________________________Date_________________