Massage Intake Form

About You
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postcode
Phone Number*
Email*
example@example.com
Occupation*
Emergency Contact
Name*

First NameLast Name
Phone Number*
Relationship*
Medical Information
Are you taking any medication?*

YesNo
Please list name and use*
Please indicate any of the folowing that apply to you

CancerHeadaches / MigrainesArthritisDiabetesJoint Replacement(s)High / Low Blood PressureNeuropathyFibromyalgiaStrokeHeart AttackKidney DisfunctionBlood ClotsNumbnessSprains and StrainsPregnantAllergiesChronic painOrthopedic Injuries
Please list your allergies*
Explain further about the chronic pain*
Please list your orthopredic injuries*
Please explain any of the conditions you have selected above
Massage Information
Have you had a professional massage before?*

YesNo
What type of massage are youseeking?*

RelaxationTherapeutic / Deep Tissue
Are there any areas (feet,face, abdomen etc..) you do not want massaged?*

YesNo
Please explain*
Please list any areas of discomfort*
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 the therapist if any of the above information chnages at any time.
Signature*

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