RnRmassage.com
Intake Form

Name
Address
Telephone-Work
Telephone-Home
E-Mail Address
Emergency Contact
Date of Birth

Have you received any professional bodywork? Yes No
If so, what kind?

What are you looking to get out of this work?

Health Survey:

Do you wear contact lenses? Yes No
Do you exercise regularly? Yes No
If yes, what is your regimen?

If female, are you pregnant? Yes No
Are you currently under a doctor's care? Yes No
If yes, for what are you being treated?

Please list any surgeries and their dates:

Are you currently taking any medication? Yes No
If yes, please list medication and reason for taking it:

Have you ever broken or fractured any bones? Yes No
Any sprains or strains?Yes No
If yes, please describe and give dates:

Please list any allergies:

Please list any other issues you feel are important for me to know:

If printing this form, please indicate below where you feel tension: If Submitting by email- you will be asked to complete the diagram in the office prior to your appointment. Thank you.

*You may be required to obtain doctor's permission prior to our first session. *