Massage Intake Form

Full Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

E-mail

Best Phone Number to Reach You

Area CodePhone Number

I prefer appointment confirmations by:

Birth Date

MonthDayYear

Occupation

Form of Payment

Medical Insurance Company

Subscriber ID #

Massage Coverage

Copayment Amount

How recently have you had a massage?

What was your most recent massage for?

What were the results of your last massage?

How are you feeling right now? What do you want from your massage? Are there any parts of your body that need special attention or areas that should be avoided?

What is your current pain level? 0 - None, 10 - Unbearable

Are you currently under the care of a physician or chiropractor?

If the answer to the above question is yes, what are you seeing them for?

Please check next to conditions that apply to you:

Please describe (if needed) any of the above conditions that apply to you. Include how long the condition has effected you, where it occurs in your body and any related secondary problems. Are there any conditions not mentioned that affect you?

Which medications (both prescription and over the counter) are you currently taking? What conditions are these for?

I understand that I will be receiving a therapeutic massage from a licensed massage therapist and the purpose of this massage is to maintain good health and physical condition. I understand that massage therapists may not diagnose illness or diseases, and massage should not take the place of a doctor's care when indicated. I agree to communicate with my practitioner at any time during the session should I feel like my well-being is being compromised or that I am uncomfortable in any way with the massage or environment. Such discomfort may include (but is not limited to) physical pain, sexually aggressive behavior, personal remarks, or requests.

Electronic Signature: please write your full name and today's date.

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Elements Holistic Wellness

Massage Intake Form