Body Therapies Patient Intake Form Personal Information Medical History Occupation/Body Specific Order Number Full Name * DOB * Age * Gender * Address City * State * Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip * Home Phone Cell Phone Work Phone Email Address * Your email address will be used for appointment confirmations, quarterly newsletters, and to alert you of specials and promotions. Occupation How were you originally referred to Bella Via? Dr. Colville Dr. Zavell Website Friend Other Medical History Please check any of the following conditions that apply to you: medical_history Arthritis/Rheumatism Asthma Back Pain Blood Clots Bursitis Cancer Carpal Tunnel Syndrome Diabetes Eczema/Psoriasis Fibromyalgia Frequent Headaches Heart Problems Hepatitis High/Low Blood Pressure Infectious Disease Immune Deficiency Disease Joint Problems Lymph Node Removal Migraine Headaches Nail/Foot Fungus Open Wounds/Infections Sciatica Seasonal Allergies Thyroid Condition TMJ Torn Rotator Cuff Varicose Veins Do you suffer from excessive stress or depression? If yes, please explain Do you have circulation problems or do you bruise easily? * Yes No Do you have any allergies to lotions/oils, seaweed/iodine, or medications? Have you ever had a stroke or any other major injury? If yes, please explain: Do you wear contact lenses? * Yes No Are you pregnant? If yes, when is your expected due date? Are you breast-feeding? Yes No Do you participate in physical/sports activities? If yes, which types and how often? List all surgeries you have had within the last five years: List any medications, herbals, and vitamins that you are currently taking: Do you have any other medical condition(s) that your technician/therapist should know about? If yes, please explain: Occupational Concerns Please check any of the following conditions that apply to you: Occupational Concerns Heavy lifting Hazardous substances Computer work Repetitive functions Prolonged sitting Prolonged standing Body Specific What are your expectations of the body treatment you will receive today? * Do you prefer a light or firm touch with your massage? Light Firm Are you interested in aromatherapy incorporated into your treatment today? Yes No Do you prefer a full-body massage, or do you have specific muscle groups that you would like your therapist to focus on during your massage? Where are your specific areas of complaint, pain or tension? Have you had a professional massage before? If yes, when? If yes, do you receive massages on a regular basis? Do you have any spinal problems? * Yes No Are you especially sensitive to touch/pressure in any specific areas? Do you have difficulty falling asleep at night? * Yes No Do you get muscle cramps? If yes, where? By submitting this form, I agree to the following statement: I understand that my body therapy session is provided for the basic purpose of stress reduction, relief from muscular discomfort, and for help in increasing blood, lymph, and energy circulation. I have stated all known medical conditions and I will keep the massage therapist updated on any changes regarding my health. I claim full responsibility for services rendered. I consent to having “Before” and “After” photographs of said procedure(s) for the purpose of documentation in my file. * These photographs MAY be used anonymously on your website or in your brochure for advertising purposes. These photographs MAY NOT be used anonymously on your website or in your brochure for advertising purposes.