Massage Therapy Intake Form printable pdf download

Massage Therapy Intake Form

Name:_________________________________ Date: ____________________________

Address: ________________________________________________________________

Postal Code:________________________ Date of Birth:__________________________

Home: ____________________Business: _________________Cell: ________________

Email: _____________________________ Occupation:__________________________

Referred By ______________________________________________________________

Please check one of the following: Email Reminders

Phone Call Reminders:

Reason for seeking treatment: _______________________________________________

How long have you had this condition? ________________________________________

Does it bother your sleep?_______ work?________ other? _________________________

What seems to make it better? _______________________________________________

Have you ever had massage before?___________________ How long ago? ___________

Are you currently taking any medication? ______________________________________

Are you currently under the care of a physician? (if yes please provide name and number)

________________________________________________________________________

Are you seeing any other therapies? ___________________________________________

Are you pregnant?__________________________ Due Date: ______________________

Medical History (do you have or had?)

__Asthma

__Cancer

__Diabetes

__Heart Disease

__Stroke

__High Blood Pressure

__Seizures

__Headaches

__Varicose Veins

__Skin Problems/Eczema __ Migraines

__Arthritis

__Allergies(including oils and creams)

__Vertigo or dizziness

__Nerve Damage

__Digestive issues __Surgeries

Have you ever been in any Motor Vehicle Accidents? If so when? ___________________

________________________________________________________________________

Please list any other conditions that you feel are pertinent to your health ______________

________________________________________________________________________

Do you exercise regularly?_________________What kind of activities? ______________

________________________________________________________________________

Are you under a lot of stress?________________________________________________

Please see next page

Massage Therapy Intake Form