Massage Therapeutics Intake Form

520 N Prospect Ave Ste 201

Redondo Beach, CA 90277

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?

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?

Other
What are your current issues & how are they affecting you?
What type of pain are you currently experiencing?

Other
How did your issue/pain begin?

Other
In your entire lifetime, have you ever had any of the following surgeries? (n/a if not applicable)

Other
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 allergies and/or skin sensitivities? (particularly relevant for some of the service enhancements offered)
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?
If pregnant, what is your gestational period?
Which prescription medications are you currently taking?

Other
Type Full Name:

First NameLast Name
Signature
Today's Date

MonthDayYear
Should be Empty:

New Client Intake Form