Sandy Pugh, Certified Massage Therapist

Intake Form
Please full out form completely, print it out and mail it in before coming
for your first treatment.  Thank you.
   

Name _______________________________________________

Phone________________________ DOB __________________

Address _____________________________________________

 City _____________________ State __________ Zip ________

Email:_______________________________________________

Referred by:__________________________________________

Phone (      ) ______________

In case of emergency:  Name_____________________________
  
          Phone_______________

Occupation __________________________  Male □   Female □

Physician ________________________________________

Have you ever experienced a professional massage or bodywork
         session?  Yes □   No □ 

         If "yes" how recently? ____________________

Do you frequently suffer from stress?  Yes □   No □ 

Do you have diabetes?  Yes □   No □ 

Do you experience frequent headaches?  Yes □   No □ 

No Are you pregnant?  Yes □   No □ 

Do you suffer from arthritis?  Yes □   No □ 

Are you wearing contact lenses?  Yes □   No □ 

Are you wearing dentures?  Yes □   No □ 

Do you have high blood pressure?  Yes □   No □ 

If you have answered “yes” to the previous question, are you taking

        medication for this?  Yes □   No □ 

Do you suffer from epilepsy or seizures?  Yes □   No □ 

Do you suffer from joint swelling?  Yes □   No □ 

Do you have varicose veins?  Yes □   No □ 

Do you have any contagious diseases?  Yes □   No □ 

Do you have osteoporosis?  Yes □   No □ 

Do you have any allergies?  Yes □   No □ 

Do you bruise easily?  Yes □   No □ 

Have you had any broken bones in the past two years?  Yes □   No □ 

Have you been in an accident or suffered any injuries in the past two years?

        Yes □   No □ 

Do you have tension or soreness in a specific area?  Yes □   No □ 

Please specify _________________________________________

____________________________________________________

Do you have cardiac or circulatory problems?  Yes □   No □ 

Do you suffer from back pain?  Yes □   No □ 

Do you have numbness or stabbing pains anywhere?  Yes □   No □ 

Are you very sensitive to touch or pressure in any area?  Yes □   No □ 

Have you ever had surgery?   Yes □   No □ 
   
        If "yes" please list___________________________________

____________________________________________________

Do you have any other medical condition, or are you taking any
medications I should know about?  Yes □   No □ 

        If "yes" please list___________________________________

Additional comments____________________________________

____________________________________________________