New Client PT Form

Massage Intake Information
Name

First NameLast Name
Email
example@example.com
Birth Date

MonthDayYear
Gender
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Height
cm
Current Weight -optional
kg
What is your massage target
Which of the following statements fit in with your massage targets?

Other
Are you using
Have you had a massage before
When did you last experience pain that may affect your massage session
What does your current diet look like?

Other
Do you smoke?
What is your daily activity level?

1

2

3

4

5

1 is None, 5 is High
What is your daily stress level?

1

2

3

4

5

1 is Low, 5 is High
How often are you training or physically active within a week?
Please rate your readiness to feel great!!.

1

2

3

4

5

1 is Worst, 5 is Best
Book your massage now
Should be Empty: