JU-ENE Body Massage Intake Form

First Name *

Last Name *

Email *

Cell Phone

Date of birth

City

Gender:

Health History

Have you had any recent surgeries or medical procedures in the past 6 months? (Yes/No) *

Yes

If Yes, Please explain

Are you currently under the care of a physician for any medical condition? (Yes or No) *

Yes

If answering yes to being under a physician care, please exlpain

Do you have any chronic pain or areas of discomfort? If yes, please explain:

Have you had a massage before? *

Yes

Are you pregnant or breastfeeding? *

Yes

If you are pregnant, how many weeks?

Do you have any specific goals or areas of focus for your massage?

How did you learn about JU-ENE? *

Preferred pressure level for the massage?

Light

Medium

Firm

Client Signature