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Massage Intake Form

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Name *

Phone *

Address *

Address Line 1

City

State

Zip Code

Occupation

Email *

Emergency Contact

Phone

Employer

Primary Physician

Relationship

How did you hear about us?

Medical Information

Are you taking any medications? *

If YES, Please list name and use

Are you currently pregnant? *

If YES, how far along?

Any high risk factors?

Do you suffer from chronic pain? *

If YES, Please explain

What makes it better?

What makes it worse?

Have you had any orthopedic injuries? *

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? *

What type of massage are you seeking? *

What pressure do you prefer? *

Do you have any allergies or sensitivities? *

Please Explain

Are there any areas (feet, face, abdomen, etc.) you do not want massaged? *

If YES, Please Explain

What are your goals for this treatment session?

Please explain any areas of discomfort

Client Signature

Clear Signature

Today's Date

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