New Client Medical Intake Form - Red Stick Massotherapy, LLC

This brief intake form helps us understand your health history and specific needs, ensuring a safe and personalized massage experience.

Your well-being is our priority, and this information helps us provide the best care possible. Thank you for taking a moment to complete it.

We respect your privacy. Your health information is confidential and used solely for your care. For inquiries or concerns, please reach out to us.
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*This document is required for all new clients and will need to be updated every 12 months.

Legal Name*

Date of Birth*

Sex Assigned at Birth*

Male

Female

Intersex

Physical Address (no PO Boxes)*

Mailing Address (if different from physical)

Mobile Phone*

Work Phone

Email Address*

Confirm Email*

List all Medications (type "na" if none)*

List all Allergies (type "na" if none)*

List all Surgeries since 2017 (type "na" if none)*

Areas of Discomfort/Pain

Rate of Overall Pain

Frequency of Pain

When Did This Pain Begin?

What Time of Day Is It the Worst?

Do You Have Any Injuries?

Anything You Do That Increases or Decreases Pain?

What Is Your Occupation?*

What Position Is Your Body In Most of the Day?*

In Which Position Do You Fall Asleep Easiest?*

On Back

Stomach sleeper

Left side

Right side

Name & Phone Number of Doctor*

Have You Had Any of the Following Events in the Last Year?*

Please Select Any that Apply*

Have You Ever Received Massage Therapy Before?*

Yes

No

Emergency Contact Name*

Emergency Contact Phone*

How did you hear about us?*