Hot Stone Therapy Intake Document
Personal Information
Full Name
Date of Birth
Phone Number
Email Address
Address
Medical History
Please check if you have/had any of the following:
Heart Disease
High Blood Pressure
Diabetes
Circulatory Issues
Skin Conditions
Recent Surgery
Varicose Veins
Pregnancy
Other medical conditions or concerns
Current Medications
Please list any medications you are currently taking
Allergies
Please list any known allergies
Session Goals
What are your goals or areas of concern for today's session?
Consent
I acknowledge that I have provided accurate information and consent to hot stone therapy.
Signature
Date