Intake Form | New Dawn Massage Center

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Contact Form

Name:

Email:

Phone:

Address:

City:

State:

ZIP Code:

Age:

DOB:

Occupation:

Emergency Contact Name:

Emergency Contact Number:

Who may I thank for your visit today?

Present symptoms (reason for visit):

Are you under the care or a Physician, Chiropractor or Physical Therapist?

Yes

If so, for what condition?

Have you ever experienced a professional massage or bodywork session?

Yes

If so, how recently?

What kind of pressure do you prefer?

Light

Medium

Firm

Please check any of the following if they apply to you:

Sinus troule

Loss of smell/taste

Touch deprivation

Allergies

Headache

Anemia

High blood pressure

Low blood pressure

Varicose veins

Tingling

Heart problems

Stroke

Fibromyalgia

Asthma

Dizziness

Recent injury

Recent surgery

Arthritis

Painful joints

Swollen joints

Numbness

Inner tension

Back pain

Disc problems

Fainting

Loss of balance

Loss of memory

Ringing in ears

Contacts

Emotional trauma

Constipation

Indigestion

Nervousness

Prostate problems

New Option

Irritability

Fatigue

Depression

Contagious disease

Diabetes

Cancer

Pregnant

TMJ

Menopausal

Thyroid problems

Skin infection

Blood clots

Other:

Do you have tension or soreness in a specific area?

Yes

Please Specify:

Are you taking any medication I should know about?

Yes

Please Specify:

Have you ever had surgery or any injuries in the past 2 years?

Yes

Please Specify:

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CANCELLATION POLICY: When you schedule an appointment, time is reserved exclusively for you. If you must cancel your appointment, a 24 HOUR NOTICE is required in order to not be charged for the appointment.

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Date:

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2039 Regency Rd

Suite 6

Lexington, KY 40503

10:00 AM-6:00 PM, Wed-Sun

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