Massage & Wellness Intake Form printable pdf download

Massage & Wellness Intake Form

Please fill out all information as accurately and thoroughly as possible.

It is the better that you give us what you consider too much information, rather than not give us enough information.

Name: ________________________________________________

Email: ___________________________________

Address: ______________________________________________

City: ___________________State: ____

Zip: _________

Phone # Work: ______________________________

Home: _________________________Cell: _____________________

Occupation: _______________________________________ Date: of Birth: ___________________________________

If Student, course of study: _______________________________

Approx. Completion Date: ___________________

Emergency Contact: __________________________________ P hone: ______________________

Relationship: ____________

How did you hear about us? _________________________________________Height: ___________ Weight:_________

Have you ever received professional massage or bodywork before: __________________________________________

What (specifically) would you like to receive from your appointment today? ________________________________

Would you like me to focus on or target any specific areas today? __________________________________________

Would you like me to stay away from any specific areas? _________________________________________________

How much pressure do you like: Light:_________ Medium: __________ Hard: _________ Don't Know: ________

FOR FACIALS ONLY:

Skin type do you have: Dry: ______ Oily: ______ Acne Prone: ______ Sensitive: ______Combination:_______

What (specifically) would you like to receive from your facial today? ________________________________

HEALTH INFORMATION

Are you or have you ever had any of the following conditions (Please check yes or no).

Yes

Contagious Disease?

Smoker?

Pregnant?

Heart Conditions?

High Blood Pressure?

Allergies?

Low Blood Pressure?

Seizures?

Diabetic?

Cancer?

Epilepsy?

Varicose Veins?

Frequent Anxiety?

Frequent Headaches?

Dementia?

Nausea?

Skin Conditions?

Surgeries?

Please explain any yes answers: __________________________________________________________

_____________________________________________________________________________________

Are you currently suffering from pain related to traumatic experience (i.e.: car accident, sports injuries, surgeries) Y / N

If yes, briefly explain (what and when): _________________________________________________________________

_____________________________________________________________________________________

Are you currently taking any medications or supplements (prescription and non-prescription) Y / N If yes list names &

dosage of all medications: ___________________________________________________________________________

_____________________________________________________________________________________

I attest that the above information is true and accurate to the best of my knowledge

Signature: __________________________ Date: _______________________

Therapists Initials: ___________

If minor, signature of guardian required: __________________________ Date: _____________________________

Disclaimer: By signing above, I agree that I understand that a massage therapist is not a doctor and cannot prescribe medication or

diagnose medical conditions. The therapists does not discriminate on the basis of race, religion, age, gender and sexual preference.

Massage & Wellness Intake Form

Related Articles

Related forms

Related Categories