Intake Form

Thank you for taking the time to fill out this intake form prior to receiving your first massage. :)

Massage Intake Form - CONFIDENTIAL INFORMATION

Welcome! I would like to make your appointment as pleasant and comfortable as possible. If at any time you have questions regarding your session, please let me know.

Full Name (required)
Your Email (required)
How did you hear about me?
Date of Birth
Address
City/State
Home Phone
Cell Phone
Can you receive Texts
Occupation
When was your last massage?
Are you taking medications?
If Yes, please list name and reason for medications
Are you currently seeing a healthcare professional
If yes, please list names and reason/treatment
Please review this list and select those conditions that have affected your health either recently or in the past. To select multiple options, hold down the CTRL key on your keyboard and click each selection.

If any of the above needs to be detailed or if there is anything else to share, please do so
Do you have any of the following today? (To select multiple options, hold down the CTRL key on your keyboard and click each selection.)
Please list any allergies
Which areas are you feeling discomfort?
What are your goals/expectations for this therapy session
Please list any areas which you would like focus work

The following sometimes occurs during massage. They are normal responses to relaxation. Trust your body to express what it needs to: need to move or change position - sighing, yawning, change in breathing - stomach gurgling - emotional feelings and/or expression
movement of intestinal gas - energy shifts - falling asleep - memories

Please read the following information below:

I understand that although massage therapy can be very therapeutic, relaxing and
reduce muscular tension, it is not a substitute for medical examination, diagnosis and
treatment.
This is a therapeutic massage and any sexual remarks or advances will terminate the
session and I will be liable for payment of the scheduled treatment.
By submitting this Intake Form you affirm that you have answered all questions pertaining to medical conditions truthfully.