CLIENT INTAKE FORM Please fill out this form prior to your appointment. Name Birth Date Address Phone Occupation In case of emergency How did you hear about Harmony Restored? Gender Gender Male Female When was your last massage? Medications Are you pregnant Do you have high blood pressure Do you have seizures Have you had surgery? Have you had a broken bone in the last 2 years Do you have allergies Do you have tension or soreness anywhere What pressure would you like Client Signature Date 15 + 14 = Submit