New Client Massage Intake Form

Make sure you are logged in to Vagaro!
1. I would like doTerra Aromatherapy and this is the scent I would like:
2. Date of Birth: *
3. Occupation: *
4. Employer:
5. Are you under the care of physician(s)? *
6. If yes, what are you being treated for?
7. Emergency Contact Name & Number: *
8. How did you hear about Skin Deep Massage Therapy? *
Medical Information Male & Female
9. Do you suffer from chronic pain?
10. Please rate your pain on a scale of 1-5. 1 Being minimal & 5 being the most painful
1 2 3 4 5
11. Please explain your chronic pain
12. What makes it better?
13. What makes it worse?
14. Are you taking any medications? *
15. If yes, please list name or use:
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 not listed above?
Female Questions (Guys, skip to Question 26)
21. Are you currently pregnant?
22. If yes, when is your due date?
23. Are there any high risk factors?
About Your Massage!
24. I would like a quiet session, so no talking *
25. If time allows, I would like to add a stretch session to my massage, my therapist will do a full body stretch on me
26. Have you had a professional massage before? *
27. If yes, when was your last massage?
28. What kind of pressure do you prefer? *
29. If 'Other' please explain:
30. I understand that if the pressure is too much or not enough I should tell my therapist immediately *
31. Do you have any allergies or sensitivities? *
32. If yes, please explain:
33. What are your goals for this treatment? *
34. I would like the table warmer:
35. I'm ok with a foot massage
36. I'm OK with the gluteal (buttocks) massage, over the sheet, on the sides only
37. I understand that breast or genital massage will not be performed *
38. I understand that draping will be used at all times by either a full size towel or sheet covering all private areas, on females the chest will stay covered at all times. *
39. I understand that if at any point during the session my therapist makes me feel uncomfortable, I can terminate the session and receive a full refund. *
40. I understand that any illegal or inappropriate behavior on my behalf, will terminate the session, and I will be responsible for payment in full, and the authorities may be contacted. *
By signing below, I agree that all the information above is true. *