Aorai Spa Intake Form

Contact Information

Name	A value is required.
Street Address:	A value is required.
City:	A value is required.
Prov/State:	Please select a valid item.
Postal Code:	A value is required.
Primary Phone:	A value is required.
Cellular Phone:
E-mail Address:	A value is required.
Age:	A value is required.
Weight:	lbs

Previous Experience

Have you ever had a massage?	Please select a valid item.
Were you content with your session?	Please select a valid item.
Have you ever had a Watsu/WaterDance/Water Session?	Please select a valid item.
Were you content with your treatment?	Please select a valid item.
Do you receive Massage/Aquatic Therapy on a regular basis?	Please select a valid item.
Do you have expectations for this visit?	Please select a valid item.

Please describe:
Name of person who referred you:

General Health Questions

Are you comfortable in water?	Please select a valid item.
Are you sensitive getting water in your ears?	Please select a valid item.
Have you had any trauma associated with the water?	Please select a valid item.
Various forms of aquatic therapy involve the practitioner holding the client while moving them through the water.
Are you comfortable with being held?	Please select a valid item.
Do you have any part(s) of your body that are sensitive to pressure or being stretched?	Please select a valid item.
Please describe:

Do you now have/or had any of the following? Check to indicate:
diabetes	sensitive to heat	arthritis
pregnant	heart disease	allergies
motion sickness	heart attack	pacemaker
metal implants	surgery	hernia
cancer	seizures	headache
high/low blood pressure		fractures
Other:

This is your session. If you are physically uncomfortable at any time, please let me know, so I can adjust your position. If you wish or need to stop the session for any reason, please let me know. These forms of bodywork make no claims to treat medically diagnosed conditions for which one should see a physician. The undersigned assumes full responsibility for his/her health and will no way hold the practitioner accountable for any outcome of the session.

Submit your name:	A value is required.
Date:	A value is required. / A value is required. / A value is required. (yyyy/mm/dd)

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Photography: Jaime Kowal

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