Intake Form Download and print this form Page 1 Page 2 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 AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Occupation*Height*feet*inchesWeight*lbsPhone*Work/Cell PhoneEmail* Referred byEmergency Contact* First Last Phone*Health ConcernsDescribe 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?*- Select -YesNoIf 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?*- Select -YesNoIf yes, what are you being treated for?Are you currently under the care of a chiropractor?*- Select -YesNoIf yes, what are you being treated for?Are you currently under the care of an alternative medicine practitioner?*- Select -YesNoIf 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?*- Select -YesNoIf 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 newsletterYesNo, thank youConsent 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. Upload signature, if possibleCaptchaEmailThis field is for validation purposes and should be left unchanged.