COUPLES MASSAGE WORKSHOP
PERSONAL INTAKE FORM
Vernal Equinox Weekend <> March 20-22, 2009
Vernal Equinox Weekend <> March 20-22, 2009
Name:
___________________________________________________
Name of Workshop partner: ___________________________________________________
Are you allergic to any nuts, oils, or scents? If "yes," please provide details.
___________________________________________________
Are you currently under the care of a physician, chiropractor, etc? If "yes," for what are you being treated?
___________________________________________________
Within the past year have you had a heart attack, stroke, surgery, broken bone, or any serious illness? If "yes," please provide details.
___________________________________________________
Please list all medications you have taken within the past 7 days:
__________________________________________________
Do you have any difficulty laying face up or face down? If "yes," please provide details.
__________________________________________________
Please mark all of the following that currently apply to you:
[ ] heart/circulatory condition
[ ] blood clotting disorder
[ ] varicose veins
[ ] cancer
[ ] kidney or liver condition
[ ] diabetes
[ ] arthritis
[ ] neck or spine injury
[ ] herniated, ruptured or slipped disk
[ ] neurological condition
[ ] elevated blood pressure
[ ] dizziness or loss of balance
[ ] acute pain
[ ] swelling
[ ] inflammation
[ ] infectious condition
[ ] contagious condition
[ ] skin condition
[ ] fever
[ ] cold, flu or virus
[ ] abscessed tooth
[ ] possibly or definitely pregnant
"I have identified all of my known physical conditions, ailments, and complaints, whether or not under a physician’s care. "
Signed: _____________________________________________
Dated: _________________________
