Massage Intake Form

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