Massage Intake Form

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Massage Intake Form

Please fill out this intake form prior to visit.

Email *

Name *

Phone Number *

Address: *

Date of Birth: *

Occupation: *

Employer:

Primary Physician:

Emergency Contact/Relationship/Phone Number *

How did you hear about us?

Are you taking any medication? If yes please list name and use: *

Are you currently pregnant?/If so, how far along?/Any high risk factors? *

Do you suffer from chronic pain?/What makes it better or worse? *

Have you had any orthopedic injuries? If yes please explain: *

Please indicate any of the following that apply to you: *

Cancer

Headaches/Migraine

Arthritis

Diabetes

Joint Replacement(s)

High/Low Blood Pressure

Neuropathy

Fibromyalgia

Stroke

Heart Attack

Kidney Dysfunction

Bloodclots

Numbness

Sprains or Strains

Other:

Required

If you said yes to any of the above, please explain:

Have you had professional massage? *

Yes

What type of massage are you seeking? *

Relaxation/Swedish

Therapeutic/Deep Tissue

Lymphatic Therapy

Other:

What pressure do you prefer? *

Light

Medium

Deep

Do you have any allergies or sensitivities? If yes please explain. *

Are there any areas (feet, face, abdomen, etc.) that you do not want massaged? If yes please list here: *

What are your goals for this treatment session? *

Please list any areas of discomfort on the body:

By submitting this form I agree that I have answered to the best of my knowledge and agree to inform my therapist if any of the above changes at any time. (Use electronic signature: Name/Date)

A copy of your responses will be emailed to the address you provided.

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