Intake Form
PERSONAL INFORMATION
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Name*
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Phone*
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Email*
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Address*
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City*
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State*
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Zip / Postal Code*
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Occupation*
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Employer*
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Date of Birth
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Primary Physician*
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Emergency Contact*
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Relationship*
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Emergency Contact Number*
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MEDICAL INFORMATION
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Are you taking any medications?*
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If yes, please list name and use:
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Are you currently pregnant?*
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If yes, how far along?
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Any high-risk factors?
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Do you suffer from chronic pain?*
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If yes, please explain
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What makes it better?
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What makes it worse?
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Have you had any orthopedic injuries?*
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If yes, please list
If yes, please list
Please indicate any of the following that apply to you:*
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Explain any conditions you may have marked above:
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MASSAGE INFORMATION
Have you had a professional massage before?*
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What type of massage are you looking for?*
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If other, please explain:
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What pressure do you prefer?*
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Do you have any allergies or sensitivities?*
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Are there any areas you do NOT want massaged?*
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List any other areas you do NOT want massaged:
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What are your goals for this treatment session?
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Select any areas you'd like me to focus on:
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BY ENTERING YOUR NAME AND CLICKING "ACCEPT TERMS" BELOW YOU AGREE TO THE FOLLOWING: I HAVE COMPLETED THIS FORM TO THE BEST OF MY ABILITY AND KNOWLEDGE AND AGREE TO INFORM MY THERAPIST IF ANY OF THE ABOVE INFORMATION CHANGES AT ANY TIME.
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Name*
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