Mountain Shadows Massage & Bodywork LLC
Intake Form
Personal Information
Name
DOB
-
Month
-
Day
Year
Date
Email
example@example.com
Phone
Format: (000) 000-0000.
City/State
How did you hear about us?
Occupation/Activities
Emergency Contact Name/Relation
Phone #
Format: (000) 000-0000.
Medical Information
Taking any medications?
no
yes
List Types
Currently pregnant?
no
yes
How far along?
Risk factors?
Suffer from chronic pain?
no
yes
Explain
Orthopedic injuries?
no
yes
Explain
Allergies, sensitivities, or skin conditions?
no
yes
Explain
Please indicate any of the following that apply to you.
Cancer
Bruise Easily
Headaches/Migraines
Diabetes
Varicose Veins
Vertigo
Fibromyalgia
Blood Clots/ DVT
Arthritis
Heart Attack/ Heart Disease
Neuropathy/ Numbness
Joint Replacement(s)
High/Low Blood Pressure
Seizures or Epilepsy
Scoliosis
Stroke
Please explain selections:
Massage Information
Have you had professional massage before?
no
yes
How often?
What type of pressure do you prefer?
Light
Medium
Firm
Deep
Unsure
Areas of focus:
Areas you do NOT want massaged?
no
yes
List areas:
Scents you do NOT like? (such as essential oils)
Would you like to receive one monthly email when we open the next month's schedule and share important updates?
Yes
No
By signing below, you agree to the following: I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time.
Client/Guardian Signature
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: