Massage Intake Form

1. Personal Information *
2. Emergency Contact: *
3. Emergency Contact Phone: *
4. Occupation:
Medical Information
5. Are you taking any medications? *
6. If yes, please list name and use:
7. Are you currently pregnant? *
8. If yes, how far along:
9. Any high risk factors?
10. Do you suffer from chronic pain? *
11. If yes, please explain:
12. What makes it better?
13. What makes it worse?
14. Please indicate any of the following that apply to you: *
15. Explain any conditions you have marked above:
16. Are there any other conditions that not listed above?
17. Have you had a professional massage before?
18. Do you have any allergies or sensitivities? *
19. If yes, please explain:
20. What are you goals for this treatment session?

I have completed this form to the best of my ability, knowledge, and agree to inform my therapist if any of the above information changes at any time.

I understand massage is intended for the relief of muscle tension, stress reduction, and general relaxation and is not a substitute for conditions requiring physician.

I understand that any illicit or sexually suggestive remarks or advances made by me will result in termination of the session and I will be responsible for payment of the entire scheduled appointment.
By signing below, I agree that all the information above is true. *