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Tropical Beach

Begin Your Healing

Massage Initial Intake
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What are your health concerns and goals?

Allergies:

Vitamins/Supplements and reason for taking:

Medications and reason for taking:

Hospitalizations:

Do you have a pacemaker?

Yes

No

Are you currently Pregnant or attempting to become Pregnant?

Yes

No

Do you suffer from any chronic pain? If yes, Please describe this pain.

Is there anything that aggravates or alleviates your discomfort?

Check all that apply to you:

Cancer

Headaches/Migraines

Arthritis

Diabetes

Joint Replacement

High/Low Blood Pressure

Neuropathy

Fibromyalgia

Stroke

Heart Attack

Kidney Dysfunction

Blood Clots

Numbness/Tingling

Sprains or Strains

Sweats easily

Hot or Cold easily

I have answered truthfully and to the best of my knowledge

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