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Client Intake Form
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Name
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First
Last
Cell Number
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Email
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Mailing Address
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Line 1
Line 2
City
State
Zip Code
Country
Occupation
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Emergency contact with phone number
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How did you hear about us?
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Internet search
Google Ads
Yelp
TripAdvisor
Print advertisement
Word of mouth
How often do you come to Steamboat?
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Full time
2nd home owner
Yearly
~2 years
2+ years
Have you ever had a professional massage? If so, how recently?
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What are your massage/bodywork goals?
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Relaxation
Therapeutic
Both
What kind of pressure do you prefer? Check all that apply.
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Light
Medium
Firm
Please take a moment to carefully read and fill out the following information. If you have a specific medical condition or symptoms, massage may be contraindicated or require a doctor’s note prior to your service.
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Stress
Diabetes
Headaches
Grind/clench teeth
Pregnancy
Dentures or contact lenses
High blood pressure
Epliepsy or seizures
Bruise easily
Osteoporosis
Varicose veins
Contagious diseases
Skin conditions
Allergies
Cardiac/circulatory problems
Back pain
If you answered "yes" to any of the above questions, please clarify:
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Have you ever had surgery, including cosmetic? Specify, including year and procedure:
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Have you ever had any broken bones? Specify, including year:
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Any other medical conditions or significant injuries? Specify:
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Do you have any numbness or stabbing pains anywhere? If so, please specify.
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Are you sensitive to touch or pressure anywhere? Is there anywhere we should avoid?
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Please list any medications you take on a regular basis, including herbal remedies:
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What are your activities of daily living? Check all that apply.
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Sitting
Driving
Standing
Phone
Bending/Lifting
Computer
Walking
Other
If you selected "other," please explain:
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Do you participate in any exercise or sports? Check all that apply.
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Skiing
Snowboarding
Running
Weights
Cardio
Biking
Hiking
Swimming
Pilates
Horseback riding
Tennis
Yoga
Golf
Other
If you selected "other," please explain:
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How much water do you drink per day?
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