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Intake Form
Personal Information
First Name
Last Name
Email
Birthday
Phone
Address
City/State/Zip
Occupation
Employer
Emergency contact
Phone
How did you hear about us?
Do you authorize us to send text & email with promotional materials:
Yes
No
Medical Information
Are you thaking any medication?
*
Yes
No
If Yes, please list name and use
Have you had any surgeries previously?
*
Yes
No
Any high risk factors?
If Yes, explain:
Do you suffer from chronic pain?
*
Yes
No
If yes, explain:
Any Orthopedic injuries?
*
Yes
No
If Yes, please list:
Please indicate any of the following:
Cancer
Headaches/Migraines
Arthritis
Diabetes
Joint replacement (s)
Pacemaker
High/Low Blood Pressure
Neurophaty
Fibromyalgia
Numbness
Stroke
Allergies
Heart Attack
Kidney Dysfunction
Blood Clots
Sprains or Strains
Eczema
Others
Explain any condition(s) you have marked above
Massage Information
Have you had a professional massage before?
*
Yes
No
What type of massage are you seeking?
Are there any areas (feet, face, abdomen, etc) you do not want to massage?
*
Yes
No
Explain:
What are your goals for this treatment session?
By signing below, you agree to the following: I have completed this form to the best of my ability, acknowledge, and agree to inform my therapist if any of the above information changes at any time, I accept terms & conditions
Submit the Intake Form
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