Intake form

Thank you for filling in your history before your visit.

This allows us to serve you better.

Massage Intake Form

Your details

Last Name

First Name

Email *

Phone *

Occupation

Date of birth

Emergency contact name

Emergency contact phone

Emergency contact relationship

Health information

Are you taking any medications?

Yes

No

If so, please list

Any allergies? (oils, nuts, fruits, skin, etc.)

Yes

No

If so, please list

Are you pregnant?

Yes

No

If yes, how many months? What is your due date?

Are you under any medical supervision or receiving any other medical interventions?

Yes

No

If yes, please describe

Select options that apply

Areas of swelling

Yes

No

Autoimmune disorder

Yes

No

Back / Neck problems

Yes

No

Bleeding disorder

Yes

No

Blood clots

Yes

No

Bruise easily

Yes

No

Bursitis

Yes

No

Cancer

Yes

No

Contagious condition

Yes

No

Decreased sensation

Yes

No

Diabetes

Yes

No

Fibromyalgia

Yes

No

Headaches

Yes

No

Heart Condition

Yes

No

Hypertension

Yes

No

Kidney Disease

Yes

No

Muliple Sclerosis

Yes

No

Neurological condition

Yes

No

Neuropathy

Yes

No

Osteoarthritis

Yes

No

Osteoporosis

Yes

No

Phlebitis

Yes

No

Sciatica

Yes

No

Seizures

Yes

No

Stroke

Yes

No

Tendinitis

Yes

No

TMJ disorder

Yes

No

Vertigo / dizziness

Yes

No

Areas of broken skin? (eg rash, wounds)

Yes

No

If yes, where?

Massage Information

How much pressure do you prefer?

Light

Medium

Firm

Reason for seeking massage?

By ticking YES below, I acknowledge that I am aware of the benefits and risks of massage therapy and that I have completed this form to the best of my knowledge. I also agree to inform my massage therapist of any health or medical changes.

Yes

No