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 also fill out our prenatal form.)
NAME*
DATE*

MonthDayYear
Date
BIRTHDATE

MonthDayYear
Date
GENDER

MaleFemaleNon-binary/Other
ADDRESS
CITY
STATE
ZIP
PHONE (MOBILE)*
EMAIL*
example@example.com
HOW DID YOU FIND OUT ABOUT US? (CHOOSE ONE)*
OCCUPATION
POSTURE ASSUMED MOST OF THE DAY
HAVE YOU HAD A PROFESSIONAL MASSAGE BEFORE?

YesNo
ANYTHING YOU REALLY LIKED OR DISLIKED ABOUT YOUR PREVIOUS MASSAGE?
WHAT KIND OF PRESSURE DO YOU PREFER?
You can always discuss it with your therapist!
DO YOU HAVE ANY DIFFICULTY LAYING ON YOUR FRONT, SIDE OR BACK?

YesNo
IF YES, EXPLAIN
EXERCISE (TYPE & HOW OFTEN)
RATE YOUR GENERAL STRESS LEVEL (1-10)
ANY SPECIFIC AREAS YOU WOULD LIKE YOUR THERAPIST TO CONCENTRATE ON?
WOULD YOU LIKE TO INCLUDE ANY ENHANCEMENTS?
RECENT SURGICAL HISTORY (INCLUDE DATE(S))*
ANY SERIOUS ACCIDENTS, FALLS OR INJURIES, CHILDHOOD ACCIDENTS? (INCLUDE DATE(S))*
ARE YOU CURRENTLY UNDER MEDICAL SUPERVISION?*

YesNo
IF YES, WHAT CONDITION?
DO YOU HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING CHRONIC CONDITIONS?

Allergies (Seasonal)AnxietyArthritisArtificial JointAsthmaCancerDepressionDiabetes Type I or IIDigestive ProblemsEasy BruisingEpilepsyFibromyalgiaHeadachesHeart ConditionHeart DiseaseInsomniaJoint DisorderHigh/Low Blood PressureOsteoporosisSpinal ProblemsTMJVaricose Veins
ANY OTHER HEALTH ISSUES YOU'D LIKE US TO BE AWARE OF? (INCLUDE SKIN ALLERGIES/SENSITIVITIES HERE)
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 I 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 I am uncomfortable in any way, I understand that I 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
CLIENT SIGNATURE DATE*

MonthDayYear
Date
GUARDIAN SIGNATURE (IF UNDER 18)

Clear
GUARDIAN SIGNATURE DATE

MonthDayYear
Date
LICENSED MASSAGE THERAPIST (LEAVE BLANK)
LMT SIGNATURE (LEAVE BLANK)*

Clear
LMT SIGNATURE DATE (LEAVE BLANK)

MonthDayYear
Date
Should be Empty: