Client Intake Form

Home
Who We Are
- Erica >
  - Bragging rights
- Chelsea
What We Do
Gift Certificates
Benefits of massage
Policies
Location
Contact
Archives
Blog

Want to schedule an appointment online?

CLICK HERE

Just can't get enough?

Subscribe to our mailing list

* indicates required

Email Address *

Client Intake Form

Name *

First

Last

Cell Number *

Email *

Mailing Address *

Line 1

Line 2

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? *

Submit

Contact us at 970.439.1782

eMail
Facebook
Twitter

✕