New Client Intake — Central Coast Healing Hands

Personal Information

First Name

Last Name

Date of Birth

Phone

Email

How did you hear about us?

Identification

Upload a photo of your government-issued ID (driver's license, state ID, or passport)

🪪

Choose a file or drag it here

JPG, PNG, or PDF · max 8 MB

🔒 Your ID is sent over an encrypted connection and stored in a private, access-restricted folder. It is used only to verify your identity, is never shared, and is deleted upon request.

Primary Reason for Visit

Select all that apply

Relaxation / Stress relief Muscle tension Chronic pain Injury recovery Prenatal support Lymphatic drainage Sports performance General wellness

Describe your main concern (optional)

Pain & Discomfort

Current pain level (0 = none, 10 = severe)

0 10

3

No pain Moderate Severe

Preferred pressure

Light Medium Firm Deep

Current Medications

I am not currently taking any medications or supplements

Medication / Supplement	Dosage	Reason for Taking	How Long

Include prescription drugs, over-the-counter medications, vitamins, and herbal supplements. Some medications may affect how your body responds to massage.

Health History

Additional health notes

Have you had a massage before?

Yes, regularly Yes, occasionally No, first time