Mojo Massage Intake Form
Welcome. This form is an invitation to share what feels relevant so that we can co-create a session that supports your body, heart, and spirit. Your information is confidential and held with care.
Contact Information
Name:
Phone:
Format: (000) 000-0000.
Email:
example@example.com
Preferred method of contact:
Phone
Text
Email
Birthday:
Emergency Contact:
Relationship:
Phone:
Format: (000) 000-0000.
Where did you hear about me?
Health History
Please check any current or past conditions:
Conditions
High blood pressure
Heart conditions
Diabetes
Recent injury or surgery
Varicose veins
Neuropathy
Pregnancy (weeks: )
Skin conditions
Chronic pain (where?):
Other (please explain):
Medications (name + purpose, if comfortable sharing):
Do you have any nut allergies?
Yes
No
Are you currently receiving treatment for a medical or psychological condition?
Yes
No
Physical Considerations
What brings you in today?
Back
Next
Where are you experiencing tension, pain, or restriction?
Are there areas of your body you prefer not to be touched?
Preferred pressure:
Light
Medium
Deep
Varies
Emotional & Energetic Awareness (Optional)
Are there emotional themes or intentions you'd like to explore or support during this session?
Are you navigating a major life transition, threshold, or spiritual process?
What would you most like to feel or experience when you leave?
Touch Comfort & Preferences
On a scale of 1-5, how comfortable are you receiving touch today?
1 (Not at all)
2
3
4
5 (Very)
Would you like to choose:
Aromatherapy/scent:
Consent & Agreement
I understand that massage therapy is not a substitute for medical care and that my therapist does not diagnose or prescribe.
I affirm that I've disclosed all relevant health information.
I agree to communicate if I feel discomfort at any time.
Signature:
Date:
-
Month
-
Day
Year
Date
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