Intake Forms Prepare for Your Wellness Journey Massage Intake Form Skin Care Intake Form Massage Intake Form "*" indicates required fields Date* MM slash DD slash YYYY Full Name*Cell Number*Email* Address, City, State, Zip Code* Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Date of Birth* MM slash DD slash YYYY Emergency Contact (Name, Relationship & Contact Number)*Are you presently on medication(s)?*YesNoIf "Yes", please explain*Have you had a recent major surgical procedure or injury?*YesNoIf "Yes", please explain*Are you currently seeing a Chiropractor, Physical Therapist, or Physician for an ongoing issue?*YesNoIf "Yes", please explain*Please indicate your stress level* 1 2 3 4 Are you allergic to any Lotions or Oils?* Yes No If "Yes", please explain (Note: I use a coconut oil infusion with different essential oils.)Circle the following conditions that apply to you, past and present. Please add your comments to clarify the condition. Musculo-Skeletal Headaches Spasms / Cramps Joint Stiffness/Swelling Broken/Fractured Bones Strains/Sprains Back, hip pain Shoulder, Neck, Arm, Hand Pain Leg, Foot Pain Chest, Ribs, Abdominal Pain Problems Walking Jaw pain/TMJ Tendonitis Bursitis Arthritis Osteoporosis Scoliosis Other Circle the following conditions that apply to you, past and present. Please add your comments to clarify the condition. Circulatory/Respiratory* Dizziness Shortness of Breath Fainting Cold Feet and/or Hands Cold Sweats Stroke Heart Condition Allergies Asthma High Blood Pressure Other Circle the following conditions that apply to you, past and present. Please add your comments to clarify the condition. Digestive Intestinal Gas/Bloating Other Crohn's Disease Diarrhea Cold Feet and/or Hands Constipation Irritable Bowel Syndrome Indigestion Colitis Circle the following conditions that apply to you, past and present. Please add your comments to clarify the condition. Nervous System Chronic Fatigue Syndrome Sleep Disorders Muscular Dystrophy Paralysis Fatigue Herpes/Shingles Multiple Sclerosis Ulcers Parkinson's Disease Epilepsy Cerebral Palsy Numbness/Tingling Other Circle the following conditions that apply to you, past and present. Please add your comments to clarify the condition. Reproductive System Pregnancy Circle the following conditions that apply to you, past and present. Please add your comments to clarify the condition. Skin Rashes Allergies Athlete's Foot Acne Impetigo Hemophelia Circle the following conditions that apply to you, past and present. Please add your comments to clarify the condition. Other Loss of Appetite Depression Difficulty Concentrating Hearing Impaired Visually Impaired Diabetes Fibromyalgia Post/Polio Syndrome Cancer Tuberculosis Other I understand that a massage Therapist does not diagnose disease, illness, or prescribe any treatment or drugs, nor do they provide spinal manipulation. I understand that if I become uncomfortable for any reason that I may ask the Therapist to end the massage session, and they will end the session. I have stated all the conditions that I am aware of, and this information is true and accurate. Signature & DatePhoneThis field is for validation purposes and should be left unchanged. Skin Care Intake Form "*" indicates required fields Full Name*Full Home Address:* Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Cell & Work Contact Number*Email Address* How do you wash your face? Soap Cleanser If soap and/or cleanser, what brand(s)?Do you use moisturizer?YesNoDo you use Glycolic Acid on a regular basis?YesNoOption 3Have you or are you currently using Retin A? *YesNoOption 3If "Yes", please specify.Are you/have you taken accutane?*YesNoIf "Yes", please specifyAre you currently seeing a Chiropractor, Physical Therapist, or Physician for an ongoing issue?*YesNoIf "Yes", please explainAre you presently taking medications?*YesOption 2If "Yes", please specify.Do you experience redness/irritation often?*YesNoDo you have heart trouble?*YesNoAre you diabetic?*YesNoAre you on a special diet?*YesNoIf 'Yes", please specifyDo you consume water daily?*YesNoIf "Yes", please estimate how much.Do you drink coffee, tea, and/or soda daily?*YesNoWould estimate how much?Do you exercise?*YesNoIf "Yes", how often? Option 1 Have you ever had a facial?*YesNoOption 3If "Yes", when was your last facial?Do you give yourself a facial at home?*YesNoIf "Yes", how often?Please list cosmetics and skincare you are currently using:How would you describe your skin texture?* Thin Thick Medium Complexion Color?* Pale Pink Olive Sallow Suntanned Other Pigmentation?* Even Uneven Birthmarks Heavy Freckling Some Freckling Other Muscle Tone?* Good Fair Fallen Facial Wrinkles?* Deep Wrinkles Crow's Feet Fine Lines through Face Broken Capillaries?* Nose Area Cheek Area Chin Are Forehead Condition?* Pimples Whiteheads Flakiness Acne Scars Blackheads Your Skin Type?* Oily Combination Dry Dehydrated Sensitive Problem Acne Couperose Mature Sun Damaged Rosacea EmailThis field is for validation purposes and should be left unchanged.
