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New Client Intake Form

Please note: if you hit RETURN, the form will submit, and then it will make you start over again. We don't know how to change this. Sorry!

First Name
Last Name
Phone Numberbest number
DOBYour date of birth
Is this a textable number?
AddressIf you prefer, your town or Asheville neighborhood will also be acceptable
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Your workWhat do you do with your time?
Massage Experiencepick one
GoalsWhat is the reason for your visit?
What type of exercise?
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Repetitive Motions?Do you have any movements you perform on a regular basis?
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Surgeries?Please list any major surgeries
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Relevant Medical History
Do you have sensitive skin?
Allergiesplease list any known allergens
Muskuloskeletalplease select any that apply
Cardiovascularplease select any that apply
Respiratoryplease select any that apply
Nervous Systemplease select any that apply
Reproductiveplease select any that apply
Skinplease select any that apply
Digestiveplease select any that apply
Psychologicalplease select any that apply
Historyplease explain any checked information with relevent dates
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Symptoms or Areas of Tightness
Please help us understand how each area feels
goodstiffpainfulsevere
Head
Neck
Shoulders
Arms
Hands/wrists
Chest
Abdomen
Upper Back
Lower Back
Hips
Upper Legs
Lower Legs
Ankle
Feet
Symptomsplease explain any symptoms you are experiencing
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