THAI MASSAGE BY FRANK HUGHES
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Client Intake Form
All information provided is for the private use of Thai Massage by Frank Hughes and will not be shared or distributed.
Getting to Know You ...
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Name
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First
Last
Email
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Phone Number
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Occupation
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Birthday (XX/XX/XXXX)
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How did you hear about Thai Massage by Frank Hughes?
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Internet Search
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Facebook
Friend
Other
If Other please specify:
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Address
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Line 1
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City
State
Zip Code
Country
In case of emergency, please contact:
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What are your goals for working with Frank Hughes?
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General and Medical Information
Have you ever had a professional massage?
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Yes
No
If you have had professional massage, how often?
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Have you ever practiced breath work?
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Yes
No
If you have practiced breath work, how often?
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Are you pregnant?
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Yes
No
If you are pregnant, how far along are you?
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Describe your self-care regimen:
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How would you say you manage stress in your life?
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Are you allergic or sensitive to any oils (essential oils, nut oils, scents?)
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Yes
No
If yes, please list oils / scents.
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Are you sensitive to touch / pressure in any area(s) (ticklish?)
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Yes
No
If you are sensitive to touch / pressure, in what area(s)?
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Are there any area(s) you do not want massaged?
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Yes
No
If areas you do not wish to be messaged, please specify: (Feet, Face, Abdomen, Other?)
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What pressure do you prefer?
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Light
Medium
Deep
Please list current medications and reason:
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Please list surgeries (type and date):
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Indicate Areas of Pain / Tension:
On a scale from 1 to 10 (10 = highest), please rate your levels of:
Stress
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1
2
3
4
5
6
7
8
9
10
Pain
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1
2
3
4
5
6
7
8
9
10
Energy
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1
2
3
4
5
6
7
8
9
10
How did your symptoms of pain / discomfort start?
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What do you think is causing your pain / discomfort?
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How long have you had the pain / discomfort?
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Is the pain / discomfort occasional?
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Yes
No
Is the pain / discomfort continuous?
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Yes
No
What makes the pain / discomfort better?
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What makes the pain / discomfort worse?
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Is the condition getting better or worse?
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Does the pain / discomfort disturb your:
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Sleep
Eating
Self-care
Walking
Housework
Work
Concentration
Energy
Mood
Relationships
Enjoyment of life
Recreation
Are you depressed?
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Yes
No
Not sure
Do you think the pain makes you feel depressed?
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Yes
No
Not sure
In what areas of the body do you have pain / discomfort:
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Specifically, how does the pain / discomfort feel?
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Aching
Throbbing
Gnawing
Cramping
Pressure
Deep Aching
Squeezing
Burning
Electric Shock
Hot
Stabbing
Shooting
Numbing
Itching
Tingling
Do you have any other symptoms in addition to pain?
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Yes
No
If you do have any other symptoms in addition to pain, please specify:
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Fear
Anxiety
Sleep problems
Irritability
Loss of appetite
Nausea
Vomiting
Constipation
Difficulty urinating
Itching
Weakness
Confusion
Sleepiness
What have you tried to treat the pain or other symptoms. If you have tried medications or other treatments, please specify if it helped and how much, as well as indicate any side effects:
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Please check all that apply:
I experience:
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Skin condition: rash, warts, hives, skin cancer, other
Lymphatic condition: swollen gland(s), nasal congestion, lymph edema
Joint problems or stiffness: arthritis, sacroiliac problems, TMJ, joint replacement(s), other
Bone condition: osteoporosis, fracture, other
Headaches, migraines
Recent injury or accident: whiplash, sprain, strain, bruise, other
Circulatory condition: high- or low-blood pressure, varicose veins, blood clots
Numbness, tingling, sciatica
Tendonitis, bursitis
Peptic Ulcer Disease
Kidney Disease
Diabetes
Cancer
Fibromyalgia
Stroke
Heart Attack
Neuropathy
If other Skin Condition, please specify:
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If other joint problem, please specify:
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If other bone condition, please specify:
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If other recent injury or accident, please specify:
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If other medical problems, please specify:
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If anything else you would like to share, please do:
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Submit
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