Massage Intake Form *Name *Phone *Address *City/State/ Zip *DOB *Occupation *Employer *Email *Primary Physician *Emergency Contact *Relationship *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 if 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/Migranes Arthritis Diabetes Joint Replacement High/Low Blood Pressure Neuropathy Fibromyalgia Stroke Heart Attack Kidney Dysfunction Blood Clots Numbness Sprains/Strains Explain any of the conditions you have marked above: *Have you had a massage before? Yes No *What type of massage are you seeking Relaxation Deep Tissue What type of pressure do you prefer? Light Medium Deep Are there any areas (face, feet, abdomen, etc.) that you do not want massaged? *Do you have any allergies or sensitivities ? What are your goals for this treatment session? *Client Signature (please type full name, and date): Leave this field blank: Submit
