Client Name:*

Today's Date:*

Address:*

City*

State*

Zip Code*

Phone:*

Email:*

Date of Birth:*

How did you find us?*

Emergency Contact Name or Parent for Minor:

Emergency Contact Phone:

Have you ever received professional massage/bodywork before?*

How recently?

What types of massage/bodywork 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)?

What kind of pressure do you prefer?*

If yes, explain

List the medications you currently take:*

Are you pregnant and months?

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

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?

Comments, questions, or concerns:

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