Forms | wrenegadewellness

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?

Yes

No

Do you have diabetes?

Yes

No

Do you experience frequent headaches?

Yes

No

Are you pregnant?

Yes

No

Do you suffer from arthritis?

Yes

No

Do you wear contact lenses?

Yes

No

Do you wear dentures?

Yes

No

Do you have high blood pressure?

Yes

No

Are you taking bloodpressure medication?

Yes

No

Do you suffer from epilepsy or seizures?

Yes

No

Do you suffer from joint swelling?

Yes

No

Do you have varicose veins?

Yes

No

Do you have any contagious disease?

Yes

No

Do you have osteoperosis?

Yes

No

Do you have allergies?

Yes

No

Do you bruise easily?

Yes

No

Any broken bones or injuries in the last two years?

Yes

No

Do you have tension or soreness in a specific area?

Yes

No

Do you have cardiac or circulatory problems?

Yes

No

Do you suffer from back pain?

Yes

No

Do you have numbness or stabbing pains?

Yes

No

Are you sensitive to touch or pressure in any area?

Yes

No

Have you ever had surgery? If yes, please explain below.

Yes

No

Do have another medical condition or are you taking medications that I should know about?

Yes

No

Heal your body, nourish your free spirit.

WRENEGADE WELLNESS

Wrenegade Wellness New Client Intake Form

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.