Intake Form

Knead Escape
Name

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date Of Birth

MonthDayYear
Date
Employer
Email
example@example.com
Are you taking any medications?
If yes, please list name and use
Are you currently pregnant?
If yes for how long?
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 mark all that apply to you
Explain any conditions you have marked above
Have you had a professional massage before?
What type of massage are you seeking?

Other
What pressure do you prefer
Do you have any allergies or sensititvities?
Please explain
What are your goals for this treatment session?
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. I agree to inform my therapist if any of the above information changes at anytime.
Today's Date

MonthDayYear
Date
Client Signature
Should be Empty:

Knead Escape