Bodywork Intake Form | WombmenThings

Name *

First

Last

Date of Birth

Phone Number

Email *

Comment or Message *

Referred By

Occupation

Emergency Contact Name

Phone Number

Have you had a professional massage before? How recently?

Circle the primary purpose of today's visit?

Pain relief
Relaxation
Therapeutic
Other

Any injuries in the past two years?

If yes where were the injuries located and when?

Other medical condition? If yes please list them

Are you taking Blood Thinners or any other medications? If yes please list them

Please select any symptoms/conditions that are current or have been present in the last six months:

Where are your areas of tension?

Select One

I understand that massage practitioners do not diagnose illness, disease, or any physical or mental disorder; nor do they prescribe medical treatment or perform spinal manipulations. I acknowledge that massage is not a substitute for medical examination or diagnosis and that it is recommended that I see a primary health care provider for that service. I have stated all known medical conditions and will update the massage practitioner in writing of any changes in my health status if necessary. *

Input your name

Body Work Intake Form