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VA Massage Intake Form

The purpose of this massage intake form is to gather critical client information for safety, to personalize the massage, and to meet legal and professional requirements.

Have you ever had a professional massage

Yes

If yes, how often do you receive massage therapy?

Please fill out this field.

Do you have ay difficulty laying on your front, back, or side

Yes

Please fill out this field.

Are you wearing

contact lenses

dentures

a hearing aid

n/a

Please fill out this field.

Is there a particular area of the body where you are experiencing stiffness, tension, pain or other discomfort

Head

Neck

Shoulders

Back

Legs

Hands

Feet

Please fill out this field.

Submit VA Authorization

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