Client Intake Form

Heartfire Massage

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Client Intake Form

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Name *

First

Last

Cell Number *

Email *

Mailing Address *

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City

State

Zip Code

Country

Occupation *

Emergency contact with phone number *

How did you hear about us? *

How often do you come to Steamboat? *

Have you ever had a professional massage? If so, how recently? *

What are your massage/bodywork goals? *

What kind of pressure do you prefer? Check all that apply. *

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. *

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: *

Have you ever had surgery, including cosmetic? Specify, including year and procedure: *

Have you ever had any broken bones? Specify, including year: *

Any other medical conditions or significant injuries? Specify: *

Do you have any numbness or stabbing pains anywhere? If so, please specify. *

Are you sensitive to touch or pressure anywhere? Is there anywhere we should avoid? *

Please list any medications you take on a regular basis, including herbal remedies: *

What are your activities of daily living? Check all that apply. *

Sitting Driving Standing Phone Bending/Lifting Computer Walking Other

If you selected "other," please explain: *

Do you participate in any exercise or sports? Check all that apply. *

Skiing Snowboarding Running Weights Cardio Biking Hiking Swimming Pilates Horseback riding Tennis Yoga Golf Other

If you selected "other," please explain: *

How much water do you drink per day? *

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Contact us at 970.439.1782

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