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Client Intake Form – Therapeutic Massage
Siam Thai Massage & Herbal SPA in Bermuda OPENING TIMES MON-SUN 10am-8pm (last appointment 7pm)
www.siamspabermuda.com
Email : siamspa.bda@gmail.com
Where did you know about us? How did you know about Siam SPA bermuda? *
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If you know from Offline event please specify
If you know from Friend, Family please specify
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Personal Information
Name *
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Phone (Day) *
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Phone (Eve)
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Address
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City/State/Zip
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Date of Birth *
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Occupation
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Emergency
Contact *
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Phone *
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The following information will be used to help plan safe and effective massage sessions. Please answer the questions to the best of your knowledge.
Date of Initial Visit *
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1. Have you had a professional massage before? *
If yes, how often do you receive massage therapy?
Your answer
2. Do you have any difficulty lying on your front, back, or side? *
If yes, please explain
Your answer
3. Do you have any allergies to oils, lotions, or ointments? *
If yes, please explain
Your answer
4. Do you have sensitive skin? *
5. Are you wearing?
6. Do you sit for long hours at a workstation, computer, or driving? *
If yes, please describe
Your answer
7. Do you perform any repetitive movement in your work, sports, or hobby? *
If yes, please describe
Your answer
8. Do you experience stress in your work, family, or other aspect of your life? *
If yes, how do you think it has affected your health?
9. Is there a particular area of the body where you are experiencing tension, stiffness, pain or other discomfort? *
If yes, please identify
Your answer
10. Do you have any particular goals in mind for this massage session? *
If yes, please explain
Your answer
Check box any specific areas you would like the massage therapist to concentrate on during the session:
Medical History In order to plan a massage session that is safe and effective, I need some general information about your medical history.
11. Are you currently under medical supervision? *
If yes, please explain
Your answer
12. Do you see a chiropractor? *
If yes, how often?
Your answer
13. Are you currently taking any medication? *
If yes, please list
Your answer
14. Please check any condition listed below that applies to you:
**If yes, how many months?
Your answer
Please explain any condition that you have marked above
Your answer
15. Is there anything else about your health history that you think would be useful for your massage practitioner to know to plan a safe and effective massage session for you?
Your answer
Draping will be used during the session – only the area being worked on will be uncovered. Clients under the age of 17 must be accompanied by a parent or legal guardian during the entire session. Informed written consent must be provided by parent or legal guardian for any client under the age of 17.
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