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I will take the time to prepare and research in order to make the most out of our time together. Please submit intake at least 48 hours prior to your session.
Massage and Movement Intake
First Name
Address
Email Address
Last Name
Phone
Date of Birth
Have you been hospitalized in the last 12 months?
No
Yes
Are you currently suffering from a medical condition, illness, or injury?
No
Yes
If you answered yes to any question, please elaborate
What are your goals and/or intentions for this session?
What types of physical movement and/or posture regularly appears in your work, daily life or recreation?
What substances are you currently taking? (Please include any/all herbs, prescription medications, supplements, recreational drugs) homeopathic remedies)
Are there any aromatherapy fragrances and/or oils that you would not like used? If yes, please list below
I declare that the info I’ve provided is accurate & complete
Initials
Today's Date
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