Therapeutic Massage Intake Form

*First Name
*Last Name
*Address Street 1
*Address Street 2
*Address City
*Address State
*Address Postal Code
*Email
Phone Number
*Birthday
*Occupation
*Emergency Contact Name
Emergency Contact Phone
*Date of Initial Visit
*1. Have you had a professional massage before?
*If yes, how often do you receive massage therapy?
*2. Do you have any difficulty lying on your front, back, or side?
*3. Do you have any allergies to oils, lotions, or ointments?
*4. Do you have sensitive skin?
*5. Are you wearing any of the following? (select all that apply)
*6. Do you sit for long hours at a workstation, computer, or driving?
*7. Do you perform any repetitive movement in your work, sports or hobby?
*8. Do you experience stress in your work, family, or other aspect of your life?
*If yes, how do you think it has affected your health?
*9. Any particular area of the body where you're experiencing tension, stiffness, pain or discomfort?
*Do you have any particular goals in mind for this massage session?
*10. Are you currently under medical supervision?
*11. Do you see a chiropractor?
*If yes, how often?
*12. Are you currently taking any medication?
*If yes, please list or provide a list of medications to keep on file if it is extensive.
*Please check any condition listed below that applies to you
*If you marked cancer, please explain: Type of cancer
*Date diagnosed
*Are you currently being treated?
*When was your last treatment?
*Are you under the care of an oncologist?
*Name of oncologist if so
If you are pregnant, how far along are you? *
If you recently had a child, how long ago did you deliver/have a cesarean? **
*Have you recently had any surgical procedures?
*If yes, please list procedure and date
Are you currently still seeing a medical professional for the aforementioned procedure? ***
*Please explain anywhere yes was chosen (please number answers to match the question number)	required
*Is there anything else in your health history for your massage practitioner to know?
*Signature of Client

Therapeutic Massage Intake Form

NAVIGATION

Gift Card Disclaimer

AGE DISCLAIMER

HOURS

Appointment Booking Details