Wrenegade Wellness New Client Intake Form

Please take the time to enter all of your answers now, or print a form to bring with you to your first visit.

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Please take a moment to cerfully revue the following information and sign where indicated. If you have a specific medical condition or specific symptoms, massage/bodywork may be contraindicated. A referral from your primary care provided may be required prior to service being provided. 
Do you frequently suffer from stress?
Do you have diabetes?
Do you experience frequent headaches?
Are you pregnant?
Do you suffer from arthritis?
Do you wear contact lenses?
Do you wear dentures?
Do you have high blood pressure?
Are you taking bloodpressure medication?
Do you suffer from epilepsy or seizures?
Do you suffer from joint swelling?
Do you have varicose veins?
Do you have any contagious disease?
Do you have osteoperosis?
Do you have allergies?
Do you bruise easily?
Any broken bones or injuries in the last two years?
Do you have tension or soreness in a specific area?
Do you have cardiac or circulatory problems?
Do you suffer from back pain?
Do you have numbness or stabbing pains?
Are you sensitive to touch or pressure in any area?
Have you ever had surgery? If yes, please explain below.
Do have another medical condition or are you taking medications that I should know about?
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t // 720.939.2079

e // hi@wrenegadewellness.com 

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