Massage Client Intake Form
Please provide your details and health information to help us customize your massage experience.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: 0000 000 000.
Email Address
example@example.com
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone
*
Please enter a valid phone number.
Format: 0000 000 000.
Do you have any of the following medical conditions?
High/low blood pressure
Heart condition
Diabetes
Pregnancy
Recent surgeries
Allergies
Emotional Changes
Sinus congestion
Headaches/Migraines
Cold virus
Alcohol within 24hrs
Kidney alignment
Sport injury
Brusises
Varicose veins
Skin conditions (eczema, psoriasis, infections)
Grief process
Recent Surgery
Chronic pain or ilness
blood clot
fever with 24hrs
Wear Contact lenses
Other
Please list any allergies (including skin sensitivities or reactions to oils/lotions)
Are you currently taking any medications? (if yes please list below)
Are you pregnant
*
Please Select
No
Yes (first trimester)
Yes (second trimester)
Yes (third trimester)
Main goals for massage treatment
*
Relaxation
Pain relief
Muscls tention
Stress relief
Improved circulation
Other
Preferred Pressure
*
Please Select
Light
Medium
Firm
Deep
What is your Occupation ?
*
Do you exercise ?
*
Please Select
Low
Moderate (3X4 per week)
High (Everyday)
Daily water intake ?
*
Please Select
Low (less than 1 litre)
Moderate (1-2 litres)
High (More that litres)
Consent Statement-Perth Natural Beauty
*
I understand that all treatments provided at Perth Natural Beauty are for relaxation and therapeutic purposes only and are not a substitute for medical advice, diagnosis, or treatment. I confirm that I have disclosed all relevant health information and agree to inform my therapist of any changes to my health or wellbeing.I consent to receiving massage therapy and understand that I may withdraw my consent or stop the treatment at any time.
Signature
*
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