Massage Intake Form

Wild Rose Massage therapy & Healing Arts

Simone Coulars
Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Birth Date

MonthDayYear
Phone Number

Area CodePhone Number
E-mail
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Intake form for Massage Session

Massage
If on medications what issues are they for?
Allergies I should be aware of?
What is your intention for the massage session?
Areas of discomfort/pain
Onset of discomfort/pain
Is this discomfort/pain due to an injury?
List all related treatments received for this injury
Is there anything you do that creates, increases or decreases pain?
What are the physical duties required of your job?
Any mental/emotional/energetic/spiritual issues that you're wishing to bring more balance to?
Any preferences in massage? Like depth of pressure, uncsented vs scented oil, ect?
If you'd like a specific type of massage or blend of modaiities, please list the one(s) you'd like included. Options: Hot stones, dry brushing, hot oil scalp treatment, relaxation massage, deep tissue, thai yoga massage, gua sha, cupping
Anything else that you'd like for me to be aware of?

Intake form for Massage Session