New Client Intake Form
Required Field
Thank you for taking the time to complete this intake form. Your answers will help Mountain Mobile Massage PLLC determine if their services are the right fit for you. Most appointment requests receive a response 1-2 business days after this form has been submitted.
Personal Info
First Name
Last Name
Pronouns
Date of Birth (MM/DD/YYYY)
Gender
Male
Female
Identify as
Identify as
Occupation
Contact Info
Mobile Phone
Work Phone
Email
Source of Referral
Address
City
Country
Australia
Canada
Ireland
New Zealand
United Kingdom
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua And Barbuda
Argentina
Armenia
Aruba
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia, Plurinational State Of
Bosnia And Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
C?te D'Ivoire
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic Of The
Cook Islands
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island And Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Isle Of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People'S Republic Of
Korea, Republic Of
Kosovo
Kuwait
Kyrgyzstan
Lao People'S Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, The Former Yugoslav Republic Of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States Of
Moldova, Republic Of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Barth?lemy
Saint Helena, Ascension And Tristan Da Cunha
Saint Kitts And Nevis
Saint Lucia
Saint Martin
Saint Pierre And Miquelon
Saint Vincent And The Grenadines
Samoa
San Marino
Sao Tome And Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia And The South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard And Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province Of China
Tajikistan
Tanzania, United Republic Of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks And Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela, Bolivarian Republic Of
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis And Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Province / State
Postal / Zip Code
Health History
Please check all of the following conditions that you currently have or have had in the past:
Surgeries
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Accidents
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High Blood Pressure
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Heart Attack
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Stroke
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Blood Clots
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Numbness/Tingling
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Diabetes
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Varicose Veins
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HIV Positive
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Contact Lenses
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Dentures
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Herniated Disc
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Ruptured Disc
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Scoliosis
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Arthritis
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Shingles
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Bursitis
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Herpes
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Deep Vein Thrombosis
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Rashes
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Warts
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Athlete's Food
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Neck Pain
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Shoulder Pain
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Back Pain
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Low Back Pain
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Cancer/Tumors
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Headaches
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Migraines
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TMJ Pain
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Broken Bones
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Infectious Diseases
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Depression
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Drug/Alcohol Dependency
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Allergies
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Other
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If Currently Pregnant: Estimated Due Date
Medications
Medication
Add Another Medication
Health Continued
Area(s) of complaint:
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Which of the following best describes what you are experiencing?
Pain
0
1
2
3
4
5
6
7
8
9
10
No Pain
Severe
Ache
Tension
Discomfort
None of the above
Other
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Anything else your therapist should know regarding your health:
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Massage History
Have you ever received a professional massage?
Yes
No
If yes, approximate date of last massage:
Massage Session Goals
Benefits you hope to experience through massage services
Balance
Flexibility
Overall well-being
Stress relief
Decreased tension
Decreased discomfort
Recover from injury
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Chronic condition management
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Other massage objectives:
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Review & Agree
Consent to Receive Care
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Financial Agreement
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Signature
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