Wilmette Massage Center Intake Form

Wilmette Massage Center Intake Form
Name*

First NameLast Name
Birth Date*

MonthDayYear
Email address*
example@example.com
Emergency Contact's Name:
Emergency Contact's Telephone*
Have you had a professional massage before?*

YesNo
If you currently having any discomfort or pain, please circle area(s) where you are feeling it.

Your pain on a scale of 1 to 10 with 1 being the least pain and 10 being the worst pain before the session was:

	1	2	3	4	5	6	7	8	9	10

1 is Least Pain, 10 is Worst Pain

Can you describe your discomfort or pain?

TinglingRadiatingDullNumbnessThrobbingBurningAching
Do you have any difficulty lying on your front, back, or side?

YesNo
If yes, please explain:
Please indicate if any of the following apply to you:

Heart AttackHigh Blood PressureLow Blood PressureStroke or AneurysmHeart ConditionVaricose VeinsBruise easilyPregnancyDiabetesKidney DiseaseHypoglycemiaMuscle strain/ painLigament StrainHeadaches/ MigrainesDizziness/ FaintingNauseaSpinal InjuryHead InjuryEpilepsy/ other seizuresConcussionAsthmaRespiratory ConditionDigestive ConditionSkin conditionDepressionAnxietyJoint DislocationBone FractureArthritisOsteoporosisSwollen JointsAching JointsRods/ Pins/ Plates/ ShuntsTransplantCorrective Lenses/ ContactsCancerHepatitisHIVAllergies
Explain if necessary
Is there anything else that you think would be useful for your massage practitioner to know to plan a safe and effective massage session for you?
The above information is accurate and true to the best of my knowledge.

I understand that massage therapists do not diagnose disease or prescribe medications. I further understand that massage therapy is not a substitute for medical attention or examination.

I take responsibility for alerting my practitioner to any physical, mental or emotional changes that occur with my health.

I also understand that cancelled or missed appointments without 24 hour notice may be charged in full for the price of missed session.
Your Signature (Required)*

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