Intake Form

Intake Form
Thank you for taking the time to fill out this required documentation. You will only have to complete this form once. We appreciate your cooperation and business.

(If you're pregnant or have recently had a baby. please fill out our prenatal form)
NAME*
DATE*

MonthDayYear
Date
BIRTHDATE

MonthDayYear
Date
FemaleMaleNon-Binary
ADDRESS
CITY
STATE
ZIP
PHONE (MOBILE)
EMAIL*
example@example.com
How did you hear of us?*
OCCUPATION
POSTURE ASSUMED MOST OF THE DAY
Have you had a professional massage before?
Anything you really liked or disliked about your previous massage?
What type of pressure do you like during your massage?
Do you have any difficulty laying on you front, side, or back?
EXPLAIN
EXERCISE? (TYPE & HOW OFTEN)
RATE YOUR GENERAL STRESS LEVEL (1 10)
Are there specific areas you would like your therapist to concentrate on?
Recent surgical history (include date)
Any serious accidents, falls or injuries, childhood accidents (include date(s))
Are you currently under medical supervision?
IF YES, WHAT CONDITION?
DO YOU HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING CHRONIC CONDITIONS?
Do you have or have you had any of the following chronic conditions?

Allergies (seasonal)DepressionHeadachesOsteoporosisDiabetes Type I or IIHeart ConditionArthritisDigestive problemsHeart DiseaseArtificial JointInsomniaVaricose VeinsAsthmaEpilepsyJoint DisorderFibromyalgiaHigh/Low Blood pressure
Other health issues you'd like us to be aware of:
Please read the following information and sign below 1. I understand that massage therapy is not a substitute for medical examination, diagnosis, or treatment. 2. This is a therapeutic massage and any sexual remarks or advances will terminate the session and will be liable for payment of the scheduled treatment 3. I affirm that I have answered all questions pertaining to medical conditions truthfully. 4. If am uncomfortable in any way. I understand that have the right to ask the therapist to cease the massage and the therapist will end the session. 5. Because all services at Zen Well are provided fully clothed, I understand there will be no draping during the massage session. 6. I understand the therapist will not engage in any breast massage.

YOU WILL REMAIN CLOTHED FOR YOUR MASSAGE. WE DO NOT ADJUST JOINTS IN ANY MASSAGE.
CLIENT SIGNATURE*

Clear
DATE*

MonthDayYear
Date
THERAPIST SIGNATURE*

Clear
LICENSED MASSAGE THERAPIST
DATE*

MonthDayYear
Date
GUARDIAN SIGNATURE (IF UNDER 18)

Clear
DATE

MonthDayYear
Date
Should be Empty:

Intake Form

DO YOU HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING CHRONIC CONDITIONS?