Moonwise Massage Intake FormPlease complete this form at least 24 hours before your appointment. Name * First Name Last Name Phone * (###) ### #### Email * I agree to receive emails about my appointment and deals from Moonwise. * Yes What is your occupation (if applicable)? * I agree to the policies listed on the website. * Yes Please check all current and/or past conditions that apply. * Headache Blood clots Bruise easily Muscle/joint pain Stroke/heart attack Active cancer Prior cancer Osteoporosis Diabetes High/low blood pressure Varicose veins Wear contact lenses Fibromyalgia Jaw clenching/teeth grinding Seizures Numbness/tingling Anxiety Depression Constipation IBS/general gut or digestion challenges Sleep challenges/insomnia Brain fog Dizziness Sluggish/low energy Disc issues Sciatica Skin condition(s) Lymph nodes removed None of the above Other Please provide details of any health history identified in the previous question. Please list any other health history/medical conditions that apply to you but weren’t listed as options above. List any medications (including over the counter), or vitamins/herbal supplements you’re currently taking (if none, type “NA”). * List any accidents, injuries, or surgeries from and include date of occurrence (if none, type “NA”). * Do you have any allergies or skin sensitivities? * Yes No Please list any oils, scents, or essential oils that you dislike or have sensitivity to (if none, type “NA”). * Are you pregnant? * Yes No Are you postpartum 6 months or less? * Yes No When was your last professional massage? (If never, type “NA”.) * How often do you typically receive massage? * Weekly Every other week Monthly Quarterly Other What is the main reason you scheduled this massage? * What activities do you feel may contribute most to your pain/stress/etc.? * Is there anything your pain/stress/etc. prevents or limits you from doing? How do you typically address your pain/stress/etc.? Please list any areas of your body that you don’t wish to receive massage. (Note this is a full body therapeutic massage, including face, scalp, and belly, but any area can be avoided if desired.) * How did you hear about Moonwise Massage? * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country What are your pronouns? Emergency Contact Name * Emergency Contact Phone # * (###) ### #### Birth Date Thank you! Your intake form has been successfully submitted.I can’t wait to care for you soon at your massage.
