Client Intake and Preferences
Eileen Monaghan, LMT | 757.553.4052 | 3630 South Plaza Trail, Suite 110 Virginia Beach, VA 23452 www.monaghan-massage.com | www.hrprenatalmassage.com

Please complete this brief Client Intake & Preferences form to the best of your knowledge before your first appointment. The following information will be used to help plan safe and effective massage sessions. It will be kept confidential, unless a separate Release Form is signed.
Email address *
Your answer
Full Name (First and Last) *
Your answer
Street address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Phone number *
Your answer
Date of Birth *
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Please send me electronic confirmations for appointments via: *
Please send me e-newsletters and special announcements via:
Emergency Contact (Full name) *
Your answer
Relationship to emergency contact *
Your answer
Phone numer of emergency contact *
Your answer
Have you received a professional massage before? *
If you answered yes to receiving a professional massage before, when was the last time you had a massage?
Your answer
How much water do you drink daily? *
Your answer
Please list areas of tension, stress or pain you wish to be addressed
Your answer
Please list any current medications (over the counter or prescribed), Vitamins and/or Herbs.
Your answer
Please list any past or present surgeries/injuries/illnesses
Your answer
Please list any known allergies (skin or internal) to oils, plants, flowers, seeds, and/or nuts.
Your answer
Please check off any of the following that apply to you.
If you check any of the above conditions, please add any extra information here:
Your answer
Do you exercise? *
If you answered yes to the exercise question, please list what kind and frequency
Your answer
How did you hear about me? *
Your answer
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