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Intake Form
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Intake Form
Please download, print, and complete this form prior to your appointment.
Download Your Form Here!
Name
Daytime Phone
Evening Phone
Street Address
City, State, Zip Code
Date of Birth
Occupation
Employer
Email Address
Primary Physician
Emergency Contact
Relationship
Phone
How did you hear about us?
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 it better?
What makes it worse?
Have you had any orthopedic injuries?
Yes
No
If yes, please list:
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.
Have you had a professional massage before?
Yes
No
What type of massage are you seeking?
Relaxation
Therapeutic/Deep Tissue
Other
If other, please explain.
What pressure do you prefer?
Light
Medium
Deep
Do you have any allergies or sensitivities?
Yes
No
If yes, please explain.
Are there any areas (feet, face, abdomen, etc.) that you DO NOT want massaged?
Yes
No
If yes, please explain.
What are your goals for this treatment session?
Please list any areas of discomfort (e.g. lower back, shoulders, neck, feet)
By typing your name below you are agreeing that your electronic signature is the legal equivalent of your manual signature on this Intake Form.
I understand.
By signing 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.
SUBMIT
