Temecula Massage by Sylvia — New Client Intake
New client intake form for massage services. Complete all applicable sections, including prenatal and reflexology questions if they apply.
Client Information
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
Emergency Contact Name
*
Emergency Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Session Goals and Body Concerns
What brought you in today?
Relaxation and stress relief
Pain relief
Tension release
Injury recovery
Prenatal support
Improve flexibility
Sports recovery
General wellness
Other
What would you most like to feel different after this session?
Body areas of concern
*
Neck
Shoulders
Upper back
Lower back
Hips
Glutes
Arms
Hands
Chest
Abdomen
Legs
Feet
Head
Other
Session focus
*
Focused work on 1 area
Focused work on 2 areas
More full-body experience (For 75 & 100 min sessions)
Preferred pressure
*
Light
Light-to-medium
Medium
Medium-to-firm
Firm
Other
Should pressure change in sensitive areas?
*
Yes
No
Unsure
Current discomfort or tension level
How long has the main concern been present?
Previous care received for this concern
Massage
Physical therapy
Chiropractic care
Acupuncture
Other bodywork
Other
Medical, Sensitivity, and Comfort Information
Important medical conditions or allergies Sylvia should know about
*
Do you have any topical or ingredient sensitivities?
*
No
Yes
If yes, please describe your sensitivities
Are you taking any medications?
*
No
Yes
If yes, please list the medications and what they are for
Have you had any recent injuries or surgeries?
*
No
Yes
If yes, please describe the injury or surgery, and date
Have you ever had a history of blood clots?
No
Yes
Are you experiencing any of these?
Circulation concerns
Numbness
Tingling
Swelling
Skin conditions or infections
Diabetes
Other
Scent sensitivity
Please Select
Prefer unscented
Mild scents are okay
Strong scents are okay
Other
Bed warmer
On
Off
No preference
Conversation preference
Please Select
Quiet
Light conversation
Follow my lead
No preference
Comfort with hot stones
Yes
No
Ask me first
Comfort with cupping
Yes
No
Ask me first
Comfort with gua sha
Yes
No
Ask me first
Comfort with dry brushing
Yes
No
Ask me first
Comfort with craniosacral work
Yes
No
Ask me first
Positioning, accessibility, or comfort needs
Prenatal Massage
Please skip this section if you are not pregnant.
How many weeks pregnant are you?
Is this a single or multiple pregnancy?
Single
Multiple
Is your pregnancy considered high risk?
No
Yes
Not sure
Are there any provider restrictions or instructions Sylvia should know about?
Have you had any recent complications or hospital visits related to this pregnancy?
No
Yes
Are you currently experiencing any of the following?
Unusual swelling
Severe or persistent headache
Dizziness
Bleeding
Cramping
Other
Which positions are most comfortable for you during massage?
Side-lying
Semi-reclined
Face-down support
Sitting upright
Other
Foot Reflexology Massage
Please skip this section if you did not book Foot Relexology (may be added into 100 min session)
What would you like reflexology to support?
Deep relaxation
Stress relief
Better sleep
Headache support
Digestive comfort
Circulation support
Pain relief
Other
Do you have any foot concerns or safety issues?
Open wounds
Active infection
Recent foot or ankle surgery
Recent foot or ankle injury
Severe swelling
Rash or skin irritation
Neuropathy or reduced sensation
Other
Are your feet ticklish or especially sensitive?
Yes
No
Somewhat
Preferred pressure (feet)
Very light
Light
Medium
Firm
Very firm
Are you comfortable with warm compresses?
Yes
No
Are you comfortable with a foot scrub?
Yes
No
Consent and Signature
Consent acknowledgment
*
I understand massage is not a substitute for medical care
I will communicate any discomfort or pressure concerns during the session
The information provided is accurate to the best of my knowledge
Typed signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Submit
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