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Massage Intake Form

Client Intake & Consent Form

To ensure the best possible care, please complete the Health History & Consent Form before your session. This form helps me understand your medical background, current concerns, and any specific needs so I can tailor your massage safely and effectively.

By signing, you acknowledge that massage therapy is for therapeutic purposes only and does not replace medical care. You also consent to treatment, agree to communicate any discomfort during the session, and confirm that you have disclosed relevant health information.

Your privacy is important—your information will remain confidential.

Please take a few moments to fill out the form before your appointment. Thank you!

Occupation:

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Have you had a professional massage before?

Yes

What type of massage are you seeking?

Targeted Therapy- Deep Tissue, Trigger Point Therapy, Myofascial Release

Therapeutic Balance- Full Body, Relaxation, Deep Tissue, Stretching/ROM, Myofascial Release

Healing Renewal - Detailed Mindful Massage, Deep Tissue, Stretching/ROM, Myofascial Release,

Ultimate Rejuvenation-Deep Tissue, Trigger Point/Detailed, Stretching/ROM, Myofascial Release

What type of pressure do you prefer?

Light

Medium

Deep

Do you suffer from choronic pain?

Yes

If yes, what chronic pain are you experiencing?

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Are you coming in for an Acute injury (recent injury )

Yes

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Are you taking any medications?

Yes

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Are you currently pregnant?

Yes

If yes, how far along?

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Do you currently have or have you ever experienced any of the following conditions? (Check all that apply)

Cancer

Headache/Migraine

Arthritis

Diabetes

Joint Replacement

High/Low Blood Pressure

Neuropathy

Fibromyalgia

Stroke

Heart Attack

Kidney Disfunction

Blood Clots

Numbness

Sprains or Strains

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Do you have any allergies or senstivities?

Yes

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Are any areas you do not want massaged?

Yes

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Where would you like to receive your massage? (Select one) ☐ In-Home Massage (Your location) ☐ Atwood Location (Exact address provided upon booking) ☐ Waterford Location

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How did you hear about me?

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