Intake Form

Health History & Wellness Info

To make sure your session is safe and customized to your needs, please take a moment to review the health info below. Your answers are confidential and help us provide the best care possible. If something doesn’t apply, feel free to skip it. You’re also welcome to share anything else you'd like us to know.
Contact Information
Name*

First NameLast Name
Date of Birth*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Address 2

CityState

Zip Code

Health History
How would you rate your overall health?
Have you had a professional massage before?

YesNo
List all current medications & the conditions they are treating*
List any major accidents or surgeries (including dates)*
If you only know the month and/or year that is fine
List any major accidents or surgeries (including dates)*
List any allergies or hypersensitivities*
Reason for initial visit

Health History & Wellness Info