Client Name:*

Preferred Name:

Today's Date:*

Address:*

City:*

State:*

Zip Code:*

Phone:*

Email:*

Date of Birth:*

Please share how you found us:*

Emergency Contact Name or Parent for Minor:

Emergency Contact Phone:

Have you ever received professional massage/bodywork before?*

How recently?

Generally, what kind of pressure do you prefer?

What are your goals/expected outcomes for receiving massage/bodywork?

How do you feel today?*

List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):

Do these symptoms interfere with your activities of daily living ( e.g., sleep, exercise, work, childcare)?

If yes, explain

List the medications you currently take:*

Have you had any injuries or surgeries in the past that may influence today’s treatment?*

Are you pregnant (yes, no, unsure) and how far along?

Select any of the following health conditions that you currently have (If you are unsure, please ask. Please answer honestly, as massage may not be indicated for the following conditions):*

Please indicate if you are experiencing or have had any of the following*

Please explain any of the above selected conditions:

Do you have any allergies, including skin sensitivities?*

Please select the type of massage therapy services or techniques that you are anticipate receiving during the massage therapy session.*

Which areas of your body do you give permission l to be worked on during your treatment? Any unchecked areas will be a voided. *

Anything else you wish to share?

Please write your full name below for client/guardian signature*