Aberdeen Massage: New Client Intake Form NEW

Aberdeen Massage: New Client Intake Form NEW

For Russell Create a HIPAA Compliant Aberdeen Massage: New Client Intake Form NEW today. Form Preview
  • Aberdeen Massage

    202 S Main St, Suite 450, Aberdeen, SD 57401

    605-377-5930 | www.aberdeen-massage.com | aberdeensdmassage@icloud.com

  • New Client Intake Form

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  • Medical History: If you have experienced any of the symptoms that is marked with an asterisk (*), please call Kelsey to discuss your medical history before booking an appointment; this is to ensure your safety and well-being.

  •   Current Past Never
    Pregnancy*
    Blood Clots*
    Pacemaker*
    Congestive Heart Failure*
    Unexplained Calf Pain*
    Varicose Veins*
    Stroke or Heart Attack*
    Cancer*
    Car Accident*
    High Blood Pressure
    Low Blood Pressure
    Epilepsy / Seizures
    Chronic Headaches / Migraines
    Chronic Dizziness / Ringing Ears
    Digestive Disease (IBS, Crohns, etc)
    Chronic Constipation
    Chronic Diarrhea
    Kidney Disease / Chronic UTI's
    Arthritis (rheumatoid, osteoarthritis)
    Scoliosis / Kyphosis / Lordosis
    Osteoporosis
    Degenerative Spine / Disk
    Broken Bone
    Allergies that Require an Epi-Pen
    Autoimmune Condition (Celiac, Hashimotos, Lupus, Graves, etc)
    Diabetes / Insulin Resistance
    Endocrine / Thyroid Condition
    Chronic Depression
    Chronic Anxiety
    Chronic Swelling
    Sensitive to Touch / Pressure
    Easy Bruising
    Shortness of Breath / Asthma
    Chronic Muscle / Joint Stiffness
    Chronic Muscle / Joint Pain
    Chronic Pain
    Chronic Numbness / Tingling
    Neurological Condition (ALS, Parkinsons, etc)
    Chronic Skin Rash
    Highly Sensitive to Certain Smells or Fragrances
    Fibromyalgia
    Multiple Sclerosis
    Memory Loss / Confusion
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