Intake Form Massage Please fill out all your information! NamePhoneStreet AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodeEmail AddressPrimary PhysicianEmergency ContactRelationshipphoneHow did you hear about us?Medical InformationAre you taking any medications?Please check one!YesNoIf yes please list name and useAre you currently pregnant?Please check one!YesNoIf Yes, how far along? Any risk factors?Do you suffer from chronic pain?Please check one!YesNoIf Yes, please explainWhat makes it better?What makes it worse?Have you had any orthopedic injuries?Please check one!YesNoIf Yes, please explainPlease indicate if any of the following applies to you.CancerHeadaches/MigrainesArthritisDiabetesJoint Replacement(s)High/Low Blood PressureNeuropathyFibromyalgiaStrokeHeart AttackKidney DysfunctionBlood ClotsNumbnessSprains or StrainsMassage InformationHave you had a professional massage before?YesNoWhat type of massage are you seeking?Please Check one!RelaxationTherapeutic/Deep TissueWhat pressure do you prefer?Please Check One!LightMediumDeepI dont know?Do you have any allergies or sensitivities?Please Check one!YesNoPlease explainAre there any areas of your body you do not want massaged? Please Check one!YesNoIf yes please explainWhat are your goals for this treatment?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 the therapist if any of the above changes. SignatureStart signing your signature hereYour browser does not support e-Signature field.Send MessageSave as Draft
