Massage Intake Form

Personal Information
1. Contact Information:
2. Date of Birth:
3. Occupation:
4. Employer:
5. Primary Physician:
6. Emergency Contact: *
7. Emergency Contact Relationship: *
8. Emergency Contact Phone: *
9. How did you hear about us?
Medical Information
10. Are you taking any medications? *
11. If yes, please list name and use:
12. Are you currently pregnant? *
13. If yes, how far along:
14. Any high risk factors?
15. Do you suffer from chronic pain? *
16. If yes, please explain:
17. What makes it better?
18. What makes it worse?
19. Have you had any orthopedic injuries? *
20. If yes, please list:
21. Please indicate any of the following that apply to you: *
22. Explain any conditions you have marked above:
23. Are there any other conditions that not listed above?
24. Have you had a professional massage before?
25. What type of massage are you seeking?
26. What pressure do you prefer? *
27. Do you have any allergies or sensitivities? *
28. If yes, please explain:
29. Are there any areas (feet, face,abdomen, etc) you do not want massaged?
30. Please list areas you do not want massaged.
31. What are you goals for this treatment session?
32. Please list any areas of discomfort:
33. Have you been under the influence of either drugs/alcohol today?
By signing below, I agree that all the information above is true. I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any information changes. *