Ann Buckner's Massage Therapy
MIDDLETOWN, PA
1st time Client Form

 

1st Appointment Only

 

Ann Buckner Massage Therapy - Intake

 

Name

Address

City                              State            Zip

Cell Phone                        Age

E-Mail

 

How did you learn about this massage therapy?

 

So I know what physical movements do you do on a regular basis, what type of wok do you do?

 

Are you allergic to or do you dislike any aromas or oils?

 

Do you have any medical conditions such as heart disease, diabetes, epilepsy, use of pacemaker, etc?

 

Do you have or have you recently had a cold, flu, or other contagious disease / symptoms?

 

Do you take medications or supplements such as painkillers, antidepressants, vitamins, aspirin, etc.?

 

How much water do you drink a day?

 

What kind of exercise do you get, and how often?

 

Have you received masssage therapy before?

 

Do you prefer a certain type of massage?

 

Please write in below, any physical challenges you would like this therapy to address.

 

 

 

I understand that this is not medical treatment. Rather that this is bodywork applied to the body to bring balance to body systems. I also understand that after treatment I must do the following 3 things.

1) Drink 2 more glasses of water than is normal for me.

2) Avoid physical exertion until after a nights sleep

3) Follow therapist instructions in regards to stretches and exercise

 

DATE

 

SIGNATURE

 

 

 

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