Summer's Massage Therapy Client Intake Form

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First Name *

Last Name *

Address *

Gender *

Female

Male

Date of Birth *

Phone Number *

Email Address *

Family Doctor Name

Family Doctor Phone Number

Emergency Contact Name

Emergency Contact Phone Number *

Do You Have A Medical Condition, Injury Or Recent Surgery *

Yes

If Yes What Is The Condition

Are you seeking Insurance Benefits *

Yes

Have You Ever Had A Professional Massage Before *

Yes

What Type Of Massage Do You Prefer *

What Type Of Pressure Do You Prefer *

Light

Medium

Heavy

How Do You Feel Today *

Are You Pregnant *

Yes

Have You Been To Summer's Massage Therapy Before *

Yes

Client Comments

Mark Any of The Following That Apply To You

Blood Clots

Infections

Heart Disease

Muscle Pain

Joint Pain

Numbness or Tingling

Swelling

Bruise Easily

Sensitive To Touch or Pressure

High Or Low Blood Pressure

Stroke

Heart Attack

Varicose Veins

Shortness Of Breath

Asthma

Cancer

Headaches Or Migraines

Dizziness

Digestive Condition

Kidney Disease

Arthritis

Osteoporosis

Scoliosis

Broken Bones

Allergies

diabetes

Depression

Memory Loss, Confusion, Easily Overwhelmed

Therapist Notes

This Section To Be Completed By Your Massage Therapist

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