HLM Client Intake | QuestionPro

Hello:
Welcome to Healthy Living Massage Inc,

We invite you to fill out this client intake form so we can gather some information on you and your health history.

If there is anything missing from the form that you would like the therapist to know before your massage, please inform the theripist prior to your massage.

Thank you and enjoy your massage!!

Laura Lyman, CEO Healthy Living Massage Inc.

Client Contact Information

* First Name :

* Last Name :

Address 1 :

Address 2 :

City :

State :

Zip :

Phone :

Email Address :

Client Date of Birth

Please indicate if you have the following:

	NO	YES
Headaches

Joint stiffness/swelling

Spasms/cramps

Broken/fractured bones

Strains/sprains

Back, hip pain

Shoulder, neck, arm, hand pain

Leg, foot pain

Chest, ribs, abdominal pain

Problems walking

	NO	YES
Jaw pain/TMJ

Tendinitis

Bursitis

Arthritis

Osteoporosis

Scoliosis

Bone or joint disease

Please indicate if you have the following:

I understand that massage therapy provided by, Laura M Lyman LMT, NCTM, CEIM, (massage therapist) is intended to enhance relaxation, reduce pain caused by muscle tension, increase range of motion, improve circulation and offer a positive experience of touch. Please write your full name in the box below indicating you have provided all information to Healthy Living Massage Inc.