Massage Intake Form Online

Skip to content

Reps and Relax

Florida Keys Health and Massage

Home
About us
Services
Scuba Fitness
Reviews
Client Login
Contact Us

Search:

Home
About us
Services
Scuba Fitness
Reviews
Client Login
Contact Us

Massage Intake Form

Please enable JavaScript in your browser to complete this form.

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

567

Our Services

Personal Training
Mobile Massage and Stretching
Scuba Fitness
Forms

INTERACT WITH US!

Instagram

Facebook

CALL US

(720) 273-2984

Privacy Policy | Accessibility Statement

Go to Top