Client Intake Form Web Site Name Street Address Date of Birth Emergency Contact Name Emergency Contact Phone Home Phone Cell Phone Email Ok to Text? Yes No Referred By Occupation Have you received professional bodywork before? * Yes No Bodywork Goal Are you currently under the care of a healthcare practitioner? * Yes No medications/vitamins Health History Have you ever had an injury to your coccyx (tail bone)? * Yes No Have you ever had a concussion? * Yes No Have you been in any car accidents? * Yes No Surgeries Any broken bones? * Yes No Any scars? * Yes No Please enter any of the following that you NOW have, or have had: Musculoskeletal Bone/Joint/Osteoporosis Tendonitis/Bursitis Arthritis/Gout Jaw Pain/TMJ Spinal Problems Coccyx (tail bone) Injury Other Respiratory Asthma Emphysema/COPD Allergies Other Nervous System Epilepsy/Seizure Numbness/Tingling Headaches/Migraine Anxiety/Depression Other Reproductive Pregnant Now Previous Pregnancies C-Section Ovarian/Menstrual Problems Other Circulatory Heart Condition Plebitis/Varicose Veins Blood Clots High/Low Blood Pressure Lymphedema Thrombosis/Embolism Stroke Other Skin Rashes Athlete's Foot Cold Sores Other Digestive Irritable Bowel Syndrome Ulcer Food Allergies Other Other Cancer/Tumors Bladder/Kidney Ailment Diabetes Fibromyalgia Chronic Pain/Fatigue Lupus/Other Autoimmune Sleep Disorder Orthodontic Braces Contact Lenses Other health info FollowFollowFollowFollow
