18927 33rd Ave W Suite B, Lynnwood, WA 98036
Health Intake Form
Name______________________________________________________ Date_of_Birth_______________________
Address_______________________________________ City__ __________________________ _Zip_ ____________
Phone_ ___________________________Work__ __________________________ _Cell_________________________
Email_________________________________________________________________________________________
Occupation/Employer__ ________________________________________________________________________
Emergency_Contact_&_Phone____________________________________________________________________
Answer the fol owing questions by circling yes or no and provide any other necessary information.
_YES_ NO_ Have_you_ever_had_a_professional_massage?_YES_ NO_ Are_you_currently_under_the_care_of_a_health_care_provider_for_a_specific_condition?__ _
____________________________________________________________________________________________
_YES_ NO_ Do you take supplements or medication (asprin, aleve, etc?) Please list medications, dosages and conditions_ _
_______________________________________________________________________________________________
_YES_ NO_ Do_you_have_any_al ergies?___________________________________________________________________YES_ NO_ Do_you_have_or_have_you_ever_had_cancer?____________________________________________________YES_ NO_ Do_you_have_or_have_ever_had_a_heart_condition?_______________________________________________YES_ NO_ Have_you_ever_had_surgery?_If_so,_when?_______________________________________________________YES_ NO_ Do_you_have_varicose_veins,_blood_clots_or_circulatory_issues?___________________________________YES_ NO_ Do_you_have_high_or_low_blood_pressure?______________________________________________________YES_ NO_ Do_you_have_diabetes?_ Is_it_control ed?________________________________________________________YES_ NO_ Do_you_have_arthritis?_Which_type?_Location?_ _________________________________________________YES_ NO_ Do_you_have_issues_with_depression,_anxiety,_etc?_ _____________________________________________YES_ NO_ Do_you_have_joint_or_bone_issues?_If_so,_where?_________________________________________________YES_ NO_ Are_you_experiencing_any_changes_in_sleeping_pattern?_________________________________________YES_ NO_ Do_you_have_any_infectious/contagious_diseases?_______________________________________________YES_ NO_ Are_you_pregnant?_If_so,_what_stage?_ _________________________________________________________YES_ NO_ Are_there_any_medical_conditions_that_your_therapist_should_be_aware_of_prior_to_treatment?_ _
____________________________________________________________________________________________
If you have any needs that require special attention please let you therapist know so that we may serve you better. If there are any
questions or concerns at any time before, during or after your treatment inform your therapist immediately.
I understand that massage therapists do not diagnose illness, disease or any other physical or mental disorders. Massage therapists
do not prescribe pharmaceuticals or medical treatment. It has been made clear to me that massage therapy is not a substitute for
a medical examination and is recommended that I see a physician for any ailments I may suffer from. I have stated all of my known
medical history and conditions and I am responsible for communicating any changes in my physical and mental health to my therapist.
Signature: ______________________________________ Date: ______________________
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