Massage Intake Form Please fill out the form before your appointment. Thank you! Personal Information * Name First Name Last Name Phone * (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Occupation / Employer Emergency Contact How did you hear about us? Medical Information Are you taking any medications? Yes No If Yes, please list name and use: Are you currently pregnant? Yes No If yes, how far along? Any high risk factors? Do you suffer from chronic pain? Yes No If yes, please explain What makes if better or worse? Have you had any orthopedic injuries? Please indicate any of the following that apply to you. Cancer Headaches/Migraines Arthritis Diabetes Joint Replacement(s) High/Low Blood Pressure Neuropathy Fibromyalgia Stroke Heart Attack Kidney Dysfunction Blood Clots Numbness Sprains or Strains Explain any conditions you have marked above: Massage Information Have you had a professional massage before? Yes No What type of massage are you seeking? Relaxation Therapeutic/Deep Tissue Other What pressure do you prefer? Light Medium Deep Do you have any allergies or sensitivities? Yes No Please explain Are there any areas (feet, face, abdomen, etc.) you do not want massaged? Yes No Please explain What are you goals for this treatment session? Please explain any areas of discomfort on your body, (Arms, legs, back, etc.) Thank you!
