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Liana Vines Intake Form

Please fill out the following form before your first session with Liana

First name

Last name

Street address

City, State

Emergency contact name

Emergency contact relationship

How would you rate your general health?

Excellent

Good

Fair

Poor

Please Select all that Apply

Pregnant

Headaches / migranes

Ringing in ears

Vertigo / dizziniess

Hearing loss

Vision problems

Vision loss

Asthma

Shortness of breath

Chronic cough

Emphysema

Bronchitis

Sinusitis

Frequent colds

Smoker

Sensory loss / change

Numbness / tingling

Sciatica

Epilepsy

Seizures

Multiple sclerosis

Fibromyalgia

Pins / plates / wires / artificial joints

Date of Birth

Zip code

Email

Phone #

Emergency contact phone #

Referred by

Have you had a professional massage before?

Yes

No

Please Select all that Apply

Arthritis

Osteoporosis

Bursitis

Cancer

Diabetes

High blood pressure

Low blood pressure

Heart attack

Heart disease

Stroke

Poor circulation

Varicose veins

Pacemaker

Hemophilia

Congestive heart faliure

Hepatitis

Depression

Anxiety

Infectious skin conditions

Lyme disease

Tendonitis

TMJ

Digestive conditions

Please list reason for visit

Initials

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

I accept terms & conditions

Thanks for submitting!

© Liana Hayes, LMT, Energy Practitioner & Reiki Master. est. 2008

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