Massage Intake Form
Please take a minute to fill in the following info
First Name
Last Name
Email
DOB
Address
Primary Physician?
Emergency Contact?
Phone Number
Medical Information
Are you currently Pregnant?
Yes
No
How Far Along?
Any Risk Factors?
Are you currently taking any medications?
Yes
No
If yes, please list name and use:
Do you suffer from any chronic pain?
Yes
No
If Yes Please Explain:
What makes it better?
What makes it worse?
Have you had any orthopedic injuries?
Yes
No
If Yes please list:
Please indicate any of the following that apply to you.
Cancer
Headaches/Migraines
Arthritis
Diabetes
Joint Replacement(s)
High/Low Blood Pressure
Neuropathy
Fibromyalgia
Stroke
Heart Attack
Kidney Dysfunction
Blood Clots
Numbness
Sprains or Strains
Explain any conditions you have marked above:
Massage Information
Have you had a professional massage before?
Yes
No
What type of massage are you seeking?
Relaxation
Therapeutic/Deep Tissue
Other:
What pressure do you prefer?
Light
Medium
Deep
Do you have any allergies or sensitivities?
Yes
No
If so please explain:
Are there any areas (feet, face, abdomen, etc.) you do not want massaged?
Yes
No
If so please explain:
What are your goals for this treatment session?
Please select any areas of discomfort.
Select an option
Arms & Hands
Shoulders
Buttocks
Abdominal
Calves
Thighs
Back
Chest
Date
Your Signature
*
Clear
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