Massage Therapeutics Intake Form

South Bay Los Angeles, CA

www.massagesouthbay.com | massagetherapeutics.southbay@gmail.com

(310) 863-7704
New Client Intake Form
Name*

First NameLast Name
Gender*
Phone Number*

Area CodePhone Number
Email*
Your Birthday*

MonthDayYear
Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code
Occupation*
Occupation
How do you prefer for Massage Therapeutics to contact you? *
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
How did you hear about me?*

FacebookInstagramGoogle SearchReferral (type name below)Other
How often do you like to get a massage/bodywork?*
When was your last massage or bodywork?*
What is more important to you?*
A deep, therapeutic massage can leave you feeling sore for a day or two. How do you feel about being sore after your massage?*
What would you prefer during your massage session? *
What are your top priorities to be addressed at your appointment?*

Low Back PainSciatic PainNeck PainHip PainTight Glutes (Butt Muscles)Shoulder IssuesTension HeadachesOther
What are your current issues & how are they affecting you?*
What type of pain are you currently experiencing?*

Stabbing PainElectrical Pain (Sharp Electric Shock)Burning PainAchy PainWidespread Pain & TendernessMuscle SpasmsTension PainSharp Pain, Localized, Small AreaNoneOther
How did your issue/pain begin?*

SlowlySuddenlyIt has gotten worse over time.It has improved over time.I'm not sure how it happened or how it progressed.N/A I do not have an issue or pain.Other
In your entire lifetime, have you ever had any of the following surgeries? (n/a if not applicable)*

Any Orthopedic SurgeryCarpal Tunnel SurgeryRotator Cuff SurgeryNeck / Back FusionKnee SurgeryHip ReplacementAnkle SurgeryGallbladder SurgeryHysterectomyAppendectomy (Appendix Removal)Breast SurgeryLymph Node RemovalOther
HEAD INJURY: Please list any significant head injuries, like concussions, being knocked unconscious, or traumatic brain injury. (n/a if not applicable)*
BODY INJURY: Please list any significant injuries to your joints, muscles, or bones. (n/a if not applicable) *
Do you have any special needs I should prepare for?
Do you have an implanted electronic device in your body (like a Pacemaker, ICD, or medicine pump)?*
Are you currently pregnant?*
Which prescription medications are you currently taking?*

I am NOT taking any prescription medications.I just take Aspirin for my heart.I take a blood thinner medication.Other
Type Full Name:*

First NameLast Name
Signature*
Today's Date*

MonthDayYear
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New Client Intake Form