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Save a step and have your client intake form filled out ahead of time :) Please answer to the best of your ability so I may render the most effective service for your specific needs!

Client Intake Form
Health Questionnaire

Please fill out the following form so I may create the best service for your needs

First Name

Email

Have you been hospitalized in the last 12 months?

No

Yes

Last Name

Date of Birth

Are you suffering from a medical condition, illness, or injury?

No

Yes

Please check all that apply: * Required

Contagious skin disease

Recent accident or injury

Recent fracture

Recent surgery

Artificial joint

Current fever/swollen glands

Allergies/sensitivity

Heart condition

High/Low blood pressure

Circulatory disorder/blood clots

Osteoporosis/Osteoarthritis

Headaches/migraines

Diabetes

Cancer

Decreased sensation

Back/neck problems

If you answered yes to any question, please elaborate

Initials

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

Bodyworx

Massage & Wellness

Serving Port Charlotte, North Port, Punta Gorda, and Sarasota, FL.

By Appointment Only in Port Charlotte

Proud Member since 2017

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Client Intake Form Health Questionnaire

Proud Member since 2017

Client Intake Form
Health Questionnaire