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Massage Intake Form

Personal Information

First name

Employer

Phone

Occupation

DOB

Email*

Address

Emergenc Contact

Relationship

Phone

Medical Information

Are you taking any medications?

Yes

If yes, please list name and use

Are you currently pregnant?

Yes

If yes, how far along? /or Any high risk factors?

Do you suffer from chronic pain?

Yes

If yes, please explain and What makes it better What makes it worse?

Have you had any orthopedic injuries?

Yes

If yes, please list:

Initials*

Please indicate any of the following that apply to you.

Cancer

Fibromyalgia

Headaches/Migraines

Stroke

Arthritis

Heart Attack

Diabetes

Kidney Dysfunction

Joint Replacement(s)

Blood clots

High/Low Blood Pressure

Numbness

Neuropathy

Sprains or Strains

Explain any conditions you have marked above:

Massage Information

Have you had a professional massage before?

Yes

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

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

Yes

Please explain

What are your goals for this treatment session?

By signing below, you agree to the following. I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time.

Date picker

Client Signature

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Therapist Signature

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Terms & Conditions

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