Juli Koplan, LMP -  Massage Intake

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* 1. Name and Contact Info

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* 2. Have you had a professional massage before?

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* 3. Do you have any difficulty lying on your front, back, or side?

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* 4. Do you have any allergies to oils, lotions, or ointments?

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* 5. Do you have sensitive skin?

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* 6. Are you wearing contact lenses, dentures or a hearing aid?

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* 7. Do you sit for long hours at a workstation, computer, or driving?

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* 8. Do you perform any repetitive movement in your work, sports, or hobby?

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* 9. Do you experience stress in your work, family, or other aspect of your life?

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* 10. Is there a particular area of the body where you are experiencing tension, stiffness, pain or other discomfort?

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* 11. Do you have any particular goals in mind for this massage session?

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* 12. Are you currently under medical supervision?

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* 13. Do you see a chiropractor?

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* 14. Are you currently taking any medication?

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* 15. Please check any condition listed below that applies to you:

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* 16. Is there anything else about your health history that you think would be useful for your massage practitioner to know to plan a safe and effective massage session for you?

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