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Intake Form

First name

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Last name

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Mobile phone

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Email

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Address

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City

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State

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ZIP

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DOB

Occupation

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Emergency Contact

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Relationship

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Emergency Contact Phone

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Are you taking any medications?

Yes

No

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Are you currently pregnant?

Yes

No

If yes, how far along?

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Do you suffer from chronic pain?

Yes

No

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Have you had any orthopedic injuries?

Yes

No

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Select which ones apply to you

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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Have you had a professional massage before?

Yes

No

What type of massage are you seeking?

Relaxation

Therapeutic/Deep Tissue

Other

Are you okay with Glutes massage ?

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What type of pressure do you prefer?

Light

Medium

Deep

Do you have any allergies or sensitivities?

Yes

No

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Are any areas you do not want massaged?

Yes

No

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Select any areas of discomfort

Head-Right Side

Head-Left Side

Head-Front

Head-Back

Neck-Right Side

Neck-Left Side

Neck-Front

Neck-Back

Shoulders-Right Side

Shoulders-Left Side

Chest

Upper Back

Upper Arm-Right Side

Upper Arm-Left Side

Lower Arm-Right Side

Lower Arm-Left Side

Hand-Right

Hand-Left

Mid Back

Mid Front

Lower Back

Abdomen

Right Side

Left Side

Pelvic Area

Buttocks

Upper Thigh-Right Side

Upper Thigh-Left Side

Back Upper Thigh-Right Side

Back Upper Thigh-Left Side

Knee-Right

Knee-Left

Back of Knee-Right

Back of Knee-Left

Shin-Right

Shin-Left

Calf-Right

Calf-Left

Foot-Right

Foot-Left