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Schedule Client Intake

 
Client Intake Form  

476 Cahaba Park Circle

Birmingham, AL 35242

(205)980-4470

 First Name:

Initial:

  Last Name:
Address:
City:

State:

Zip Code:

Home Phone:

(e.g. 205-980-9873)

 Business Phone:

(e.g. 205-980-4470):
Occupation:

Date of Birth:

 (e.g. mm/dd/yyyy)
Marital Status:  

Number of Children:

How Did You Hear About Us:

E-Mail Address:
Please enter medical information below if you will be receiving any type of massage therapy services:

Check if you are taking any medication:

     If so, for what conditions:

What are your eating habits:

What are your sleeping habits:

What are your exercise habits:
Check any that apply to you:
    Sinus                     Back Aches                Heart Problems            Lung Problems             Whiplash
    Headaches            Feet/Leg Aches         Poor Circulation           Arthritis                       Pregnant
    Neck Aches           Allergies                     Chronic Colds/Flu        Bursitis                         Other #1
    Shoulder Aches     Diabetes                    Vericose Veins             Surgery                        Other #2
    Have you ever had a broken bone or other serious injury?  If so, please list:
                  Check if you consider your job stressful:   Check if you consider you personal life stressful:
Why are you here:
PLEASE READ THE FOLLOWING STATEMENTS AND CHECK THE BOX BELOW:

 

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- A Day Spa, 476 Cahaba Park Circle, Birmingham, AL 35242
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