Intake Form Please complete the form below Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Date Of Birth * MM DD YYYY Occupation Emergency Contact Person * Emergency Contact Phone # * (###) ### #### Are you currently under a physicians care for an acute or chronic illness? * Yes No If yes, please explain: Are you taking any prescribed medication(s) or dietary supplements? * Yes No If yes, please explain: Have you received a massage before? * Yes No How did you hear about Joyful Bodies? * What are your goals for this session? Checkbox * Abdominal /digestive problems Allergies Anxiety Arthritis/tendonitis Asthma or lung cond. Athletes foot Blood clots Chronic pain Circulatory/heart problems Constipation/diarrhea Depression Diabetes Fatigue Headaches, migraine Hearing problems Hernia High blood pressure Jaw pain/TMJ pain Low blood pressure Muscle/bone injuries Muscle/joint pain Numbness/tingling Pregnancy Rash/fungus Sinus problems Sleep difficulties Spinal disorders Sprain/strain Tension/stress Vision problems Varicose veins Please list any recent injuries or surgeries within the past 5 years: Please type name as your signature & acknowledgement below: * I have stated all conditions that I am aware of and this information is true & accurate to the best of my knowledge.I will inform my massage therapist if anything changes in my status. I understand that massage/bodywork I receive is for the purpose of stress reduction and the relief from muscular tension, spasm, or pain and to increase circulation. If I experience any pain or discomfort, I will immediately inform my massage therapist so that the pressure and/or methods can be adjusted to my comfort level. I understand that my massage therapist does not diagnose illness or disease, nor perform any spinal manipulations. and does not prescribe any medications/treatments. I acknowledge that massage is not a substitute for a medical examination or diagnosis and that I should see my health care provider for those services. If I am unable to attend my scheduled appointment, I will respect and abide by the set cancellation policies. Sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature will constitute as sexual harassment and will not be tolerated. I understand that I am receiving massage therapy at my own risks. In the event that I become injuries either directly or indirectly as a result, in whole or in part, of the aforesaid massage therapy I hereby hold harmless and indemnify the therapist, their principals, and agents from all claims and liability whatsoever. First Name Last Name Date Of Signature ? * MM DD YYYY COVID-19 Policy * Covid-19 as an infectious virus that currently has no direct treatment and for which there is no current vaccine. While we have taken reasonable steps to limit the potential for transmission of COVID-19 in our studio, you agree that you understand that transmission of COVID-19 is still possible. By necessity, massage therapy requires that our therapist is within 6 feet of you and will need to touch you and the potential chance of COVID-19 transmission. It may be necessary that you quarantine and/or take other steps in the event it is determined that you may have been exposed to COVID-19 are subject to modifications. I understand the COVID-19 situation and assume all risks associated with treatment during this time. Thank you!