Client Intake Form - Maroc Hamam Spa Frisco, TX

CLIENT PROFILE

Thank you for completing our client profile. This profile will assist us in identifying relevant medical or lifestyle information that may affect the service you have scheduled with us today and for your future visits.

Name(Required)

First Name Last Name

Phone(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Birthday(Required)

MM slash DD slash YYYY

Email Address(Required)

Occupation

Work Phone

Emergency Contact(Required)

How did you hear about us?(Required)

Please list anything you may be allergic to:

Are you pregnant or think you may be pregnant?(Required)

Yes

If yes, how many months?(Required)

Are you claustrophobic?

Yes

Do you have Diabetes?

Yes

Have you had a professional massage before?(Required)

Yes

If yes, how often do you receive massage therapy?(Required)

Do you have any difficulty lying on your front, back, or side?(Required)

Yes

If yes, please explain(Required)

Do you have any allergies to oils, lotions, or ointments?(Required)

Yes

If yes, please explain(Required)

Do you have sensitive skin?

Yes

Do you wear contact lenses, have dentures or us a hearing aid?

Yes

Do you sit for long hours at a workstation, computer, or driving?

Yes

If yes, please describe(Required)

Do you perform any repetitive movement in your work, sports, or hobby?

Yes

If yes, please describe(Required)

Do you experience stress in your work, family, or other aspect of your life?

Yes

If yes, please describe(Required)

Is there an area of the body where you are experiencing tension,stiffness or discomfort?

Yes

If yes, please describe(Required)

Are you currently under medical supervision?

Yes

If yes, please explain(Required)

Do you see a chiropractor?

Yes

If yes, please explain(Required)

Are you currently taking any medication?

Yes

If yes, please explain(Required)

Please check any condition listed below that applies to you:

Contagious skin condition

Varicose veins

Recent accident or injury

Recent surgery

Sprains/Strains

Swollen glands

Circulatory disorder

Heart condition

Phlebitis

joint disorder / rheumatoid arthritis/osteoarthritis/tendonitis

epilepsy

cancer

decreased sensation

Fibromyalgia

carpal tunnel syndrome

Open sores or wounds

Easy bruising

Recent fracture

Artificial joint

Current fever

Allergies/Sensitivity

Atherosclerosis

High or low blood pressure

deep vein thrombosis/blood clots

osteoporosis

headaches/migraines

diabetes

back/neck problems

TMJ

Tennis elbow

Please explain any condition that you have marked above:

Is there anything else about your health history that you think would be useful for your massage practitioner to know to plan a safe and effective massage session for you?

Clients under the age of 17 must be accompanied by a parent or legal guardian during the entire session. Informed written consent must be provided by parent or legal guardian for any client under the age of 17.

Signed on the(Required)

Date(Required)

Client’s Signature(Required)

Printed Name(Required)

Contact Info

CLIENT PROFILE