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Massage Therapy Intake FormLast name _______________________ First name ________________________ M.I. ______ Date ________Street _______________________________________________ City ____________________ State ____ Zip ________Home ph: ________________________ Work ph: _______________________ Cell ph: ________________________Will it be possible to text you? Y/N e-mail: ____________________________________________________Age __________ Date of Birth _______________________ Gender: M/F/otherEmployer ________________________________________ Occupation _______________________________________Have you received massage before? Y/N Referred by: ________________________________________Why have you come for massage today?_____ Injury _____ Pain _____ Tension _____ Stress _____ Feels goodAre you currently:Pregnant? Y/N (how many weeks?: _____) Currently experiencing the Cold or Flu? Y/N Taking medication? Y/N Skin reactions to massage oil? Y/NList Injuries/Surgeries/Major Illnesses (dates): __________________________________________________________________________________________________________________________________________________________________________________________________________________Any of the follow? (circle)Allergies Diarrhea Migraines Swollen feetAnemia Dislocations Muscle spasms TendonitisArthritis Diverticulitis Numbness TinglingAsthma Epilepsy/seizures Phlebitis TMJBack pain Eczema Psoriasis Varicose veinsBunions Headaches Rashes WhiplashBursitis Heart attack Respiratory problems Cancer Hemophilia Sciatica Women only:Circulatory issues Herpes Stiff joints Excess bleedingColitis HBP Sprain/strain Lack of periodsConstipation HIV/AIDS Excess stress Menstrual crampsDiabetes LBP Stroke PMSMark E. Hughes, LMT CKTT CCTMassage Kinesio Taping CuppingLicense #: MA641510508 Whitman Ave. N. #D, Seattle, WA 98133mark@(425)761-8321 ................
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