Intake Form

This form is for health and consent reasons for services provided by God's Healing Hands Massage Services. The information collected from this form will be used to provide effective services and treatment plans for clients as well as inform clients of upcoming appointments, events, and promotions. This form is required by the Department of Health and the Board of Massage Therapy. Please fill out this form to the best of your knowledge. Your information will not be sold.

Today's Date

First name

Last name

Address

Phone

Email

Birthday

How did you hear about God's Healing Hands?

In Case of Emergency

ICE Number (please add area code)

Do you have any allergies? (Food or topical)

Are you currently under the care of a physician?

Yes

No

Are you currently pregnant?

No

1st Trimester

2nd Trimester

3rd Trimester

Massage Questions

Please answer the questions in this section if you are receiving a massage service for your upcoming visit. (Facial questions are in next section)

Have you had a massage before?

Yes

No

What is the purpose/intended outcome for your upcoming service?

Relaxation

Pain Management

Anxiety

Other

On average. how many hours do you spend sitting? (approx.)

On average, how many hours do you spend standing? (approx.)

What level of physical activity do you participate in?

None

Light (cardio, light weightlifting/core, yoga)

Medium (cardio, moderate-heavy weightlifting, recreational sports)

Intense (heavy cardio/weights, any contact sport, body building, race training, etc.)

Have you been hospitalized or had any major surgeries within the last 5 years? (List year and reason)

Esthetics (Facial) Questions

Please answer the questions in this section if you are receiving ANY esthetic/facial service for your upcoming visit.

Is this your first facial?

Yes

No

What is your skin type?

Normal

Oily

Combination

Dry

Indicate areas of concern

Have you been under the care of a dermatologist within the last year?

Yes

No

Have you experienced an allergic reaction to any of the following?

Have you used Retin-A, Renova, AHAs, Retinol/Vitamin A within the last 3 months

Yes

No

Have you had Botox, Restylane, or Collagen injections within the last 6 months?

Yes

No

Liability Release

I have completed this form to the best of my knowledge. I understand that any complications brought about by lack of information on my part releases God's Healing Hands Massage Services from all legal liability.

Signature