Health History & Intake Form

Health History & Intake Form

Please complete this form to help us understand your health background and goals for your session!! The more information you provide, the better that I can meet you in creating a healing space for your mind, body and soul.
Name*

First NameLast Name
Preferred Name
Date of Birth

MonthDayYear
Pronouns
FemaleMaleNon-binaryPrefer to self describePrefer not to sayTransgenderNoneOther
assigned male at birthassigned female at birth
Occupation
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to You
YesNo
YesNo
What current health problems are you experiencing and what are your reasons for coming in?*
List any other healthcare providers or modalities you are currently working with or have worked with in the past.
What are your goals for this treatment?*
Past surgeries or hospitalizations?*
Chronic painMuscle tensionHeadaches/migrainesFatigueDigestive issuesSleep disturbancesAnxiety/depressionNumbness/tinglingSwellingNoneOther
Please list current areas of pain on a scale of 0-10 with 10 being the worst ever and 0 being none at all. Please include up to 3 injuries or pain areas and rate each one for: right in this moment, over the last 2 weeks, and over the last 2 months.
Example: Left shoulder — 6/10 now, 7/10 over the last 2 weeks, 5/10 over the last 2 months.
Cesarean (C-section)ForcepsVacuumVaginalOther
SingleMarriedDivorcedSeparatedWidowedPartneredPrefer not to say
YesNo
List any medications you are currently taking:
List any vitamins or supplements you are currently taking:
Please list any major illnesses or diagnoses (past or present):
Please describe your current stress level:
YesNo
YesNo
Are you the parent of any children? If so, please list their names and ages.
Family History
Please include close relatives such as parents, siblings, children and grandparents and note any significant illnesses, diagnosis or cause of death if relevant.
Massage Preferences

A few optional questions to help us create the best experience possible.
Things you have liked in past massages
Things you have disliked in past massages
Your sensory needs or awareness you would like the provider to have
Trauma-Informed Care

Optional questions to help us support your comfort, safety, and consent during care.
What you share here is kept completely confidential and is used only to help guide your treatment. You can share as much or as little as you want, and you may change your mind about any part of care at any time.
Brief check-ins throughoutOnly check in at the start and endCheck in only if neededNo verbal check-ins unless I ask
Minimal talkingOccasional talkingFrequent talkingI prefer to guide the communication fully
Are there any triggers, areas to avoid, boundaries, or other considerations we should know about?
Are there any accommodations or reasonable supports that would help you feel more safe, grounded, or comfortable during your session?
Is there any past trauma or bodywork-related experience you would like to share, if relevant and only if you feel comfortable?
Should be Empty:

Health History & Intake Form

Massage Preferences

Trauma-Informed Care