New Client Intake Form
www.DanielleMansfield.com
Heal Our Souls LLC
Bodywork Specialist, Reiki Master, Shamanic Practitioner
Personal Information
Name *
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Phone: *
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Address: *
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DOB:
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Occupation:
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Email: *
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Emergency Contact: *
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Relationship: *
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Phone: *
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How did you hear about me? *
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Medical Information
Are you taking any medications? *
If yes, please list name and use:
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Are you currently pregnant?
If yes, how far along?
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Any high risk factors?
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Do you suffer from chronic pain? *
If yes, please explain:
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What makes it better?
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What makes it worse?
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Have you had any orthopedic injuries? *
If yes, please list:
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Please indicate any of the following that apply to you. *
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Explain any conditions you have marked above:
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Massage Information
Have you had a professional massage before?
What type of massage are you seeking? *
What pressure do you prefer?
Do you have any allergies or sensitivities? *
Please explain:
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Are there any areas (feet, face, abdomen, etc.) you do not want massaged?
Please explain:
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Please list any areas of discomfort: *
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By signing below, you agree to the following. I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time.
Client Name *
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Date *
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Signature *
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