Massage Therapy Intake Form - Raya Wellness
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1
2Raya Ioffe, BA, LMT, HC, AADP
518-229-3033
10 Larkspur Drive, Latham NY 12110
Massage Therapy Intake Form
Contact Information
Name
_______________________________________________________
Date
_______________________
Address
_____________________________________________________
City
_______________________
State
________________________________
Zip
_______________
Country
_______________________
Phone (Work)
_______________
Phone (Home)
__________________
Phone (Mobile)
______________
Email
_________________________________________________
Date of Birth
______________________
Occupation
________________________________
Referred by
___________________________________
Health Information
Have you received massage therapy before? ❏ Yes
❏ No
If yes, what type(s)?
_____________________
__________________________________________________________________________________________
List current medications, including ibuprofen, herbs, and supplements:
_________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
List regular physical activities:
_________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Have you ever had any of these? (Please place a check by any that pertain to you)
❏ Accident
❏ Sprains
❏ Varicose veins
❏ Neck pain
❏ Seizures
❏ Diabetes
❏ Whiplash
❏ Headaches
❏ Allergies to nuts
❏ Abdominal pain
❏ High blood pressure
❏ Currently pregnant
❏ Disc problem
❏ Nervous tension
❏ Stroke
❏ Mid back problems
❏ Arthritis, bursitis or gout
❏ Heart attack
❏ Low back problems
❏ Allergies to oils or perfumes
❏ Cancer
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