Massage Intake Form

1. Contact Info
Personal 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 pressure do you prefer? *
26. Do you have any allergies or sensitivities? *
27. If yes, please explain:
28. What are you goals for this treatment session?
By signing below, I agree that all the information above is true. *