Health Intake Form

Health Intake Form
Full Name*

First NameLast Name
What is your gender (assigned at birth)?*
Preferred Pronouns*
Date of Birth
Contact Number*
Format: (000) 000-0000.
Email Address*
example@example.com
Street Address Address Line 2 City State Zip
Emergency Contact First Name Emergency Contact Last Name Emergency Contact Phone
Referred by:
Is this massage/bodywork medically necessary (is it for a medical condition, injury, surgery?)* Yes No
YesNo
How recently?
What types of massage/bodywork do you prefer?*
LightMediumFirm
What are your goals/expected outcomes for receiving massage/bodywork?*
How do you feel today?
List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness, tingling, swelling, etc.)*
Do these symptoms interfere with your activities of daily living (e.g. sleep, exercise, work, childcare?)
If yes, explain:
Are there any areas of your body that you would prefer not to be worked on?*
Have you had any injuries or surgeries in the past that may be impacted by today's treatment?*
AsthmaCancerCardiac diseaseDiabetesHypertensionPsychiatric disorderEpilepsyBlood ClotsCongestive heart failureOther
Chest painRespiratoryCardiac diseaseCardiovascularHematologicalLymphaticNeurologicalPsychiatricGastrointestinalGenitourinaryWeight gainWeight lossMusculoskeletalOther
YesNo
Please list them.
YesNoNot Sure
Please list them.
Signature
Date/Time
Should be Empty: