New Client Intake Form New Client Intake FormWelcome to our online Client Intake Form This information will be sent directly to our clinic and will help us to better serve your healthcare needs. All your information is kept discreetly and securely. Please fill out this form, and press the SUBMIT button at the end. Name* First Last Date of Birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email* Your email will NOT be shared with any third parties.Phone - Preferred*How did you find out about our services?*Existing clientSearch engineOtherCould you add detail for how you found out about us. Thanks.*Are you involved in any sport / leisure / recreation?* Not at the moment Jogging Swimming Cycling Walking Tennis Gym Crossfit Weightlifting Powerlifting Bodybuilding Martial Arts List any other sport / leisure / recreation? Please include any activities you are involved in that may further our understanding of your needs. Have you had any kind of previous treatment/s? Please list:* Any current injury and/or condition requiring attention or care:* What are some goals you would like to achieve from your treatment?* CHECK ALL OF THE FOLLOWING CONDITIONS WHICH YOU ARE EXPERIENCING Allergies Arthritis Back Problems Blood Clots Bruising Cancer Cramping Depression Epilepsy Fatigue Headache Heart Condition High Blood Pressure Low Blood Pressure Inflammation Insomnia Joint Problems Pregnancy Sciatica Sinus problems Skin Problems Ticklishness Varicose Veins Further explanation on existing or other conditions: Do you wear contacts?*Please choose oneYesNoDo you have any infectious conditions: HIV; Hep A, B, C; Other:*Any recent surgeries?* Any medication you are currently taking:* LEGAL INFORMATION: By submitting this form, I agree that I have read and understand the following -* I AGREE I understand that massage is not a replacement for medical care and that no medical diagnosis will be made. Because massage and bodywork therapy may be contraindicated due to certain medical conditions, I affirm that I have informed the therapist of all known medical conditions and will keep the therapist updated as to any changes in my medical condition going forward. If I experience any pain or discomfort during the session, I will immediately inform the therapist so that the pressure and/or manipulation, draping or environment may be adjusted to my level of comfort.Email Policy* Yes, I got it. Your privacy is important to us. We will only use you email for appointments, some promotion, and news about ACTIVE SOMA. We will not give your details to anyone. Any news or promotional emails will provide the option to subscribe at the bottom. IN CASE OF CANCELLATION* I AGREE I agree to give 24 hours advance notice of scheduled session, or to assume responsibility for payment of the full fee.