Inspire Massage Intake Form
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First Name *
Last Name *
Preferred form of communication *
Provide details for preferred communication; cell#, email address, phone# *
Emergency Contact Name and Phone:
How did you learn about Inspire Massage? *
What is the reason you scheduled a massage? *
Have you ever received professional massage/bodywork before?  How recently? *
What level of pressure do you prefer? *
Light
Firm
Goals for massage and expected outcomes, check all that apply. *
Required
Do you have sensitive skin?
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Has anything applied topically to your skin given you a rash, please explain. *
Check all appropriate options regarding special needs *
Required
List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):  
 *
 Do these symptoms interfere with your activities of daily living (e.g., sleep, exercise, work, childcare)? Explain:  
 *
Please list all past and recent injuries, surgeries, car accidents with dates and details. *
Check all that apply for past/current treatments used to improve your health or recover from an injury. *
Required
Are you under the care of a doctor for a current health condition? If yes, please briefly explain. *
Check all that apply
Are you pregnant? If yes, how many weeks at time of appointment? Due date?
How many months ago was your most recent labor and delivery?
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