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
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Emergency Contact
*
First
Last
Contact Phone
*
-
Area Code
Phone Number
Occupation/Hobbies:
(Helpful to know how your body is being used)
Please choose a spa robe/wrap size preference:
*
Small to Medium
Medium to Large
Large to Extra Large
Extra Large to 2 XL
2XL to 3XL
Have you ever received professional massage therapy?
*
Yes
No
If yes, when?
-
Month
-
Day
Year
Date
What type of massage have you received?
Swedish
Deep Tissue
Hot Stone
Myofascial
Cupping
Other
Not Sure
What is your goal for today?
*
Use of essential oils in session:
Yes-Ok with me
No- please do not use
What type of pressure do you like?
*
Light
Medium
Firm
Deep
What is your stress level in general?
*
1
2
3
4
5
Not much
Off the charts
1 is Not much, 5 is Off the charts
Provide any specific areas that may be causing you pain, discomfort, or soreness today:
*
Any areas for practitioner to avoid?
*
None
Head
Face
Feet
Buttocks
Other
Is there any chance you are pregnant?
Yes
No
Pregnancy Due Date
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?
*
**In the last three years
Please check any current or past conditions:
*
Are you presently under a physician's care?
*
Yes
No
If yes, please provide specific on condition being treated:
Anything else you'd like your service provider to know?
*
Release and informed consent for massage therapy:
*
Signature
*
Please verify that you are human
*
Submit
Should be Empty: