Bangkok Thai Spa Intake Form
Please take a moment to fill personal information and carefully read the following information and sign where indicated. If you have a specific medical condition or specific symptoms, massage/bodywork may be contraindicated. A referral from your primary care provider may be required prior to service being provided.
Name *
Your answer
DOB *
Your answer
Phone *
Your answer
Address *
Your answer
Email *
Your answer
Referred by
Your answer
In case of emergency: ( Name and Phone no. ) *
Your answer
Occupation
Your answer
Have you ever experienced a professional massage or bodywork session? *
what are your massage of body work goal?
Your answer
What kind of pressure do you prefer?
Are you under 18 year's old? *
Are you pregnant? *
Do you have diabetes? *
Do you frequently suffer for stress?
Do you experience frequent headaches? *
Do you suffer from arthritis?
Are you wearing contact lenses?
Are you wearing dentures?
Do you have high blood pressure? *
Are you taking high blood pressure medication? *
Do you suffer from epilepsy or seizures?
Do you suffer from joint swelling?
Do you have varicose veins? *
Do you have any contagious diseases? *
Do you have osteoporosis? *
Do you have any allergies? *
Do you bruise easily?
Any broken bones in the past two years?
Any injuries in the past two years?
Do you have tension or soreness in a specific area?
Do you have cardiac or circulatory problems?
Do you suffer from back pain?
Do you have numbness or stabbing pains?
Are you sensitive to touch or pressure in any area?
Have you ever had surgery? *
Please explain your past surgery if yes
Your answer
Other medical condition, or are you taking any medications I should know about?
Your answer
Comments
Your answer
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