New Client Intake FormPlease provide answers to the following to help us in providing background on your condition. Today's Date MM DD YYYY Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Home Phone (###) ### #### Mobile (###) ### #### Email * Message * Referred By: About Previous Treatment Have you ever received a professional massage? Yes No If so, when? Modality The type of massage therapy you received Deep Tissue Trigger Point Swedish Other Primary reason for this appointment Briefly describe Area(s) of complaint or tension Your general health status Poor Fair Good Excellent Have you had any minor or major surgery? Details please Have you had any minor or major accidents? Details please Do you have any minor or major scars? Please detail where Thank you!
