Massage Intake Form

Massage Intake Form
Name

First NameLast Name
Preferred pronouns
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Birthday

MonthDayYear
Date
Referred By:
Massage Information
Reason for Initial Visit
Have you had a professional massage before?
What type of massage are you seeking?
What pressure do you prefer?
Are there any areas you do not want massaged?
What are your goals for this treatment session?
Do you suffer from chronic pain?
If yes, please explain. Also, what makes it feel better/worse?
Please list any areas of discomfort (shoulders, low back, feet etc)
Have you received Cupping Therapy before?
Cupping Therapy - Please read and check every box if receiving Cupping Therapy
Medical Information
Are you taking any medications?
If yes, please list name and use:
Are you currently pregnant?
If yes, how far along? Any high risk factors?
Have you had any injuries or surgeries?
Your Doctor and Contact Information
Please indicate any of the following that apply to you.
Explain any conditions you have marked above.
Do you have any allergies or sensitivities? If yes, please explain.
Emergency Contact/Relationship
Emergency Phone Number
By signing below, you agree to the following.
I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time.
Signature
Date

MonthDayYear
Date
Should be Empty:

Massage Intake Form

Massage Information

Medical Information