Health Intake Form

Please fill out the following form prior to your scheduled massage.

First Name

Email Address

Last Name

Date of Birth

Address

Phone

Please indicate any of the following you have had or currenly have

Headaches/ migraines

Allergies

Arthritis/ tendonitis

Cancer/ tumors

Heart/ circulation problems

High/ low blood pressure

Joint replacement/ surgery

Blood clots

Neck/ back injury

Diabetes

Recent injury

Neuropathy/ numbness

Chronic Illness

Pregnancy

Please explain any conditions that you have marked above

Have you tested positive for COVID-19?

Yes

No

If yes, please provide when you received a negative test

What type of massage are you seeking?

Relaxation

Therapeudic/ Deep Tissue

Prenatal

Cupping Therapy

What type of pressure do you prefer?

Light pressure

Medium pressure

Deep pressure

What is the area of focus for this massage session?

If you were referred by an existing client, here's your chance to shout them out :)

By checking this box I agree to the following. I have completed this form to the best of my ability and knowledge and agree to inform my massage therapist if any of the above changes. I consent to massage therapy and understand that I am responsible for consulting a qualified physician for any physical ailment I may have.

I will provide on-site parking for the therapist and agree to pay any valet or street meter parking if required.

I agree to provide a clean space for the therapist to set up the massage table and work space. I also agree to remove any excessive amounts of animal hair from the floor in that area to prevent allergic reaction to the therapist.

Your Signature

Today's Date

Thanks for submitting!

MISSION Statement

Bodywork by Amanda's mission is to provide consistently excellent holistic bodywork and massage therapy. Promoting health and wellness to improve the quality of life for all is a priority.

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