familyfriendlychiro.com - Massage Intake Form

Massage Intake Form
Personal Information
Name

First NameLast Name
Phone (day)
Please enter a valid phone number.Format: (000) 000-0000.
Phone (evening)
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
DOB

MonthDayYear
Date
Occupation
Employer
Email
example@example.com
Primary Physician
Emergency Contact
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
How did you hear about us?
Medical Information
Are you taking any medications?
If yes, please list name and use:
Are you currently pregnant ?
If yes, how far along?
Any high risk factors?
Do you suffer from chronic pain?
If yes, please explain:
What makes it better?
What makes it worse?
Have you had any orthopedic injuries?
If yes, please list:
Please indicate any of the following that apply to you:
Explain any conditions you have marked above:
Massage Information
Have you had a professional massage before?
What type of massage are you seeking?
What pressure do you prefer?
Do you have any allergies or sensitivities?
Please explain:
Are there any areas (feet, face, abdomen, etc.) you do not want massaged?
Please explain:
What are your goals for this treatment session?
Please circle 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 my therapist if any of the above information changes at any time.
Client Signature:
Date:

MonthDayYear
Date
Should be Empty:

Massage Intake Form

Personal Information

Medical Information

Massage Information