New Client Intake Form If you have not yet received a massage at TD3 Therapeutics by Tamra Dozer, please fill out the form below. First Name Last Name Email Phone Employer Occupation Emergency Contact Emergency Contact Phone Emergency Contact Relationship How did you hear about us? Are you taking medications? Yes No If yes, please list name and use. Are you currently pregnant? Yes No If yes, how far along? Any high risk factors? Do you suffer from chronic pain? Yes No If yes, please explain: What makes it better? What makes it worse? Have you had any orthopedic injuries? Yes No If yes, please list Please indicate any of the following that apply to you Cancer Headaches/Migraines Arthritis Diabetes Joint Replacement(s) High/Low Blood Pressure Neuropathy Fibromyalgia Stroke Heart Attack Kidney Dysfunction Blood Clots Numbness Sprains or Strains Explain any of the conditions you have listed above Have you had a professional massage before? Yes No What type of massage service are you seeking? Athletic Cupping Deep Tissue Kineso Taping Lymphatic Relaxation/Swedish Other What pressure do you prefer? Light Medium Deep Do you have any allergies or sensitivities? Yes No If yes, please explain Are there any areas (feet, face, abdomen, etc.) you would not want massaged? Yes No If yes, please explain What are your goals for this treatment session? I agree with the following: I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time. submit