Intake Form

Name

Phone

Email

Date of Initial Visit

Date of Birth

Occupation

How do you hear about me

Occupation

Emergency contact name, phone number and relationship

Are you taking any medications? If yes, please list name and use.

Any allergies? (Oils, lotions, nuts, fruits, skin, etc.) Yes No

If yes, please list

Are you pregnant? Yes No

If yes, how many months?

Due Date?

Do you suffer from chronic pain? Yes No

If yes, what makes it better and worse?

Are you currently under medical supervision or receiving other medical interventions? Yes No

If yes, please describe.

Please check any of the following that apply to you:
Cancer
Headaches/Migraines
Contagious condition
Arthritis
Diabetes
Joint replacement
High/Low Blood Pressure
Neuropathy
Fibromyalgia
Stroke
Heart attack
Blood clots
Numbness
Sprains
Areas of swelling
Bruise easily
Varicose veins
Vertigo/Dizziness
TMJ disorder
Tendinitis
Sciatica

Areas of broken skin? (e.g Rash, Wounds) Yes No

If yes, where?

Any past injuries or medical procedures? Yes No

If yes, please describe

Have you had a professional massage before? Yes No

If yes, how recently?

Reason for seeking massage