Massage Therapy Intake Form - Integrative Bodywork & Massage

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IntegratIve Bodywork & Massage
Massage Therapy Intake Form
CONFIDENTIAL INFORMATION
Today’s Date
Name
Date of Birth
Address
City
State
Zip
Phone (home)
(work/cell)
email
Occupation
Height
Weight
Emergency contact name & number
Referred by:
Are you currently in pain or experiencing any discomfort? If so, please briefly explain and indicate
those areas below
Describe any chronic pain/tension
Are you currently under the care of a physician, chiropractor or alternative medicine practitioner? If
yes, what are you being treated for?
Is this massage/bodywork medically necessary (medical condition, injury, surgery)? Yes
No
Do you have a physician referral/prescription?
Yes
No
Please list any medications (prescription or non-prescription), vitamins and supplements you are
currently taking:
Are you currently pregnant?
How many weeks_________________________
Have you ever had cancer? If so, was it past or present? What type? _____________________
____________________________________________________________________________

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