Personal Information

  • Name

  • Phone(day)

  • Phone(Evening)

  • Address

  • City/State/Zip

  • DOB

  • Email

  • Primary Physician

  • Emergency Contact

  • Relationship

  • Phone

  • How did you hear about us?

    • Medical Information

  • Are you taking any medications?

    Yes No

  • Are you currently pregnant ?

    Yes No

  • Do you suffer from chronic pain ?

    Yes No

  • Have you had any orthopedic injuries?

    Yes No

    • Please check any of the following that apply to you.

    • Cancer
    • Headaches/Migraines
    • Arthritis
    • Diabetes
    • Joint Replacements
    • High/Low Blood Pressure
    • Neuropathy
    • Fibromyalgia
    • Stroke
    • Heart Attack
    • Kidney Dysfunction
    • Blood Clots
    • Numbness
    • Sprains or Strains

  • Explain any conditions you have marked above:

      • Massage Information

    • Have you had a professional massage before?

      Yes No

    • What type of massage are you seeking?

      Relaxation Therapeutic/Deep Tissue Other

    • What pressure do you prefer?

      Light Medium Deep

    • Do you have any allergies or sensitivities?

      Yes No

    • Are there any area (feet, face, abdomen, etc) you do not want massaged?

      Yes No

    • What are your goals for this treatment session?

        • Please check box that best represents area of body with discomfort

    By Signing below, you agree to the following.
    I have completed this form to the best of my ability and knowledge
    and agree to inform my therapist if any of the above information
    changes at any time.Massage Intake form is secure,
    confidential and HIPPA compliant.

  • Client Signature (Your Name Here)

  • Date