Massage Intake Form
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2Massage Intake Form
Name___________________________________________Date_____________________
Address__________________________________________________________________
City/St/Zip________________________________________________________________
Phone: Home___________________Cell__________________Work_________________
Email______________________________________DOB___________________________
Emergency Contact__________________________Phone__________________________
Y
N
Where you referred here? If so, whom?____________________________
_________________________________________________________________________
General Medical Information
Y
N
Have you ever had a professional massage? If yes, when and
what type?_______________________________________________________________
Y
N
Are you currently pregnant? If so, how far along ____________________
Y
N
Are you currently under the care of a Doctor? If so, please state
the reason._______________________________________________________________
Y
N
Are you currently taking any medications? If so, please list them.
_________________________________________________________________________
_________________________________________________________________________
Please list any other medical conditions or other medical information below.
_________________________________________________________________________
_________________________________________________________________________
On a scale of 1-10, 10 highest, rate your levels:
Stress________
Pain_________
Energy________
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Parent category: Business