Client Intake Form | Second Wind

Personal Information

First Name *

Last Name *

Date of Birth *

Phone Number *

Email Address

Emergency Contact Name *

Emergency Contact Phone *

Health History

Current injuries, surgeries, or medical conditions

Surgeries in the past 12 months?

Do you have any of the following? (Check all that apply)

High or low blood pressure Blood clots or circulatory issues Cancer or currently undergoing treatment Diabetes Osteoporosis or bone density issues Skin conditions, open wounds, or rashes Pregnancy Nerve damage or neuropathy None of the above

Current medications affecting circulation, pain, or skin sensitivity?

Allergies to oils, lotions, or scents?

Your Session

Areas of focus today

Current pain or discomfort level (1 = none, 10 = severe)

1 — None10 — Severe

1

Pressure preference *

Light Medium Firm Deep — as much as possible Let the therapist decide based on what they feel

Have you received professional massage therapy before? *

Yes No

What brings you in today?

Areas to avoid completely

Anything else your therapist should know?

Consent & Waiver

Please read and check each statement below. All three are required to submit this form.

Signature

Type your full name below. Your typed name serves as your electronic signature under the federal ESIGN Act.

Printed Name *

Date