Massage Therapy Intake

Massage Therapy Guest Intake

Enjoy your massage!
Todays date

MonthDayYear
*

First NameLast Name
*

Area CodePhone Number
Date of birth*

MonthDayYear
Email*
*

Street Address

Street Address Line 2

CityState

Zip Code
Emergency Contact*

First Last
Contact Phone*

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

YesNo
If yes, when?

MonthDayYear
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?

YesNo
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, oils, nuts, none )
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