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Samadhi Thai Massage

Traditional Thai Massage Training based in Nelson, BC and Calgary, AB, Canada

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Intake Form

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Please submit this form before your appointment.

Samadhi Thai Massage Intake Form

Please fill in all fields.

Today's Date*
Name*
First Last
Birthdate*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Occupation*
Height*
feet
*
inches
Weight*
lbs
Phone*
Work/Cell Phone
Email*
Referred by
Emergency Contact*
First Last
Phone*
Health Concerns
Describe any pain/tension. For how long?*
Is your pain/tension worse in the morning or evening?
Does your work or any other activity increase your pain/tension?
Do you have any restrictions in movement?*
If yes, where?
Are there any stretches you think may be harmful?*
Current Medical Issues and Treatments:
Past Medical Issues and Treatments:
Are you currently under the care of a physician?*
If yes, what are you being treated for?
Are you currently under the care of a chiropractor?*
If yes, what are you being treated for?
Are you currently under the care of an alternative medicine practitioner?*
If yes, what are you being treated for?
Please list any medications, vitamins and supplements you are currently taking:*
Are you currently receiving any other body or energy therapies?*
If yes, what for?
Please check any of the following that apply to you (in the past or currently)
- Heart problems
- High blood pressure
- Blood clots
- Varicose veins
- Pacemaker
- Neurological problems
- Headaches
- Arthritis
- Osteoarthritis
- Wear contact lenses
- Pregnant
- Diabetes
- Surgery
- Epilepsy or Seizures
- Back problems
- Spinal problems
- Disc problems
- Joint problems
- Accidents or injuries
- Major illness or disease
- Recent breaks/sprains
How frequently and for how long do you exercise and what do you do? Include sports, yoga, gardening, other physical activities.
I would like to receive Samadhi Thai Massage's newsletter
- Yes
- No, thank you
Consent for Thai Bodywork Treatment
- By checking this box, I understand the purpose of Thai Bodywork is for relaxation and that it is not meant to diagnose or treat any illness, disease or any other physical or mental disorder, injury or condition. I have informed my Thai Bodywork practitioner about my state of health and any recommendations and restrictions on the part of my medical doctor or therapist insofar as bodywork is concerned.
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Accreditation & Membership:

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