Massage Intake Form

Personal Information
1. Date of Birth: *
2. Occupation:
3. Primary Physician:
4. Emergency Contact: *
5. Emergency Contact Relationship: *
6. Emergency Contact Phone: *
7. How did you hear about us?
Medical Information
8. Are you taking any of the following types of medications? *
9. Are you currently pregnant? *
10. If yes, how far along:
11. Any high risk factors?
12. Do you suffer from chronic pain? *
13. If yes, please explain:
14. What makes it better?
15. What makes it worse?
16. Have you had any orthopedic injuries? *
17. If yes, please list:
18. Please indicate any of the following that apply to you: *
19. Explain any conditions you have marked above:
20. Are there any other conditions that are not listed above?
21. Have you had a professional massage before?
22. What pressure do you prefer? *
23. Do you have any allergies or sensitivities? *
24. If yes, please explain:
25. What are your goals for this treatment session?
By signing below, I agree that all the information above is true. *