Massage Intake Form
What are your goals for this treatment session?*
Name*
Phone (day)*
Address*
City*
State*
Zip*
Date of birth*
Email*
Credit Card Number:*
Expiration Date*
CVV # *
Occupation*
Employer*
Primary Physician*
Emergency Contact*
Relationship*
Emergency Contact Phone*
How did you hear about us?*
Are you taking any medications?*
Yes
No
If yes, please list name and use:
Are you currently pregnant?*
Yes
No
If yes, how far along?
Any high risk factors?
Do you suffer from chronic pain?*
Yes
No
If yes, please explain
What makes it better?
What makes it worse?
Have you had any orthopedic injuries?*
Yes
No
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
Please indicate any of the following that apply
Fibromyalgia
Stroke
Heart Attack
Kidney Dysfunction
Blood clots
Numbness
Sprains or Strains
Explain any conditions you have marked above:
Have you had a professional massage before?*
Yes
No
What type of massage are you seeking?*
Relaxation
Therapeutic/Deep Tissue
Other
If "other" selected above, please describe:
What pressure do you prefer?*
Light
Medium
Deep
Do you have any allergies or sensitivities?*
Yes
No
Please describe any areas of discomfort on your body, in detail:*
Please explain any other details on health history:
Are there any areas (feet, face, abdomen, etc.) you do not want massaged?*
Yes
No
If "yes" answered above, please explain:
Preferred aromatic scent *