Mia Bohanan LMT - Intake Form
Please fill out the intake form before your schedule appointment

If something does not apply to you please put N/A.
Email *
First Name *
Last Name *
Date of Birth *
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Today's Date *
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Phone *
Email *
Address ( also include: City, State, Zip Code) *
Emergency Contact - Name *
Emergency Contact - Phone Number *
How did you learn about us?
Have you received massage therapy before? *
Do you exercise? *
What type of exercise and how many times a week? *
Are you on any medications? *
If Yes, please list the medications and what they are treating? *
Surgeries - List the surgery and date. *
Allergies - List any allergies you have. *

Headaches and/or Migraines - Have you seen a professional? How frequently does this happen?

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Muscular and/or Soft Tissue - Bruises, sprains, strains, tendonitis, etc. Please explain where and when.

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Skeletal - Please explain where and when. Did you recieve treatment? Scoliosis, Bursitis, Fractures, Osteomalacia, Osteoarthritis, Rheumatoid Arthritis, Firous Dysplasia, etc.

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Joint Function - Where and when? Lupus, Arthritis, Osteoarthritis, Gout, Rheumatoid Arthritis, Ankylosing Spondylitis, etc.

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Joint Function - Where and when? Lupus, Arthritis, Osteoarthritis, Gout, Rheumatoid Arthritis, Ankylosing Spondylitis, etc.

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Cardiovascular - Heart Disease, Pacemaker, Stroke, Valve disease, etc.

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Cancer - What type? When? Any Surgeries? Are you being treated? Are you in remission?

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Endocrine - Diabetes, PCOS, Cystic Fibrosis, Neuropathy, etc.

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Diabetes - Are you currently being treated? Are you on certain medication? Is it controlled?

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Skin Issues - Acne, Eczema, Rosacea, Psoriasis, Cold Sore, Hives, Rashes, etc.

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Pregnancy - Are you currently pregnant?

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Varicose veins - Where is it located? How long have you had them?

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Blood Clots - Have you been treated? Are you on blood thinner medication?

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PTSD and/or Anxiety - Any concerns or nervousness with massage?

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Other - Please let me know if there is anything I should know before our session?

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Which areas of the body that has pain, tension, or an old injury that I should know about.

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Informed Consent - By answering all the questions on this intake form, you consent to the massage session. As a client I will inform my massage therapist if there is any discomfort or areas that I do NOT want included in my massage.

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Cancellation Policy - If you need to cancel your appointment please give your therapist 24 hours notice. If you fail to notify your therapist within the timeframe you will be charged 50% of your session. If you fail to show up (NO SHOW), you will be responsible and charged for 100% of your session. You will not be able to book until charge is fulfilled.

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