Massage Therapy Intake

Massage Therapy Guest Intake

Enjoy your massage!
Todays date

Month Day Year
*

First Name Last Name
*

Area Code Phone Number
Date of birth *

Month Day Year
Email *
*

Street Address

Street Address Line 2

City State

Zip Code
Emergency Contact *

First Last
Contact Phone *

Area Code Phone Number
Occupation/Hobbies:
(Helpful to know how your body is being used)
Have you ever received professional massage therapy? *

Yes No
If yes, when? *

Month Day Year
Date
What type of massage have you received? *
What is your goal for today? *
Provide any specific areas that may be causing you pain, discomfort, or soreness today: *
Any areas for practitioner to avoid? *
What type of pressure do you like? *
Is there any chance you are pregnant?

Yes No
Pregnancy Due Date

What is your stress level in general? *

	1	2	3	4	5

1 is Not much, 5 is Off the charts

Known allergies or sensitivities: *
(Food, plants, none etc)
Are you taking any medications, supplements, or herbal remedies? *
Type NONE if not applicable
Any recent surgeries or injuries? *
last three years
Please provide any health conditions you have experienced/are experiencing *
Are you presently under a physician's care? *
If yes, please provide specific on condition being treated:
Are there any present or re-occurring conditions you are managing? *
Release and informed consent for massage therapy: *
Signature *

Clear
Please verify that you are human *
Should be Empty:

Massage Therapy Guest Intake