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Massage Intake Form
ZG Therapy will never take, use, or sell your personal information to any third party or affiliates. This form is necessary and mandatory in order to provide you with services.We are fully compliant with the Code of Ethics of the National Certification Board and therefore the client/customer will disrobe to the extent that they are comfortable with and that after having been disrobed, that any part of the body that is not being massaged will be appropriately draped.
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Email
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Your email
Date Session
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Name - First/Last
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Your answer
Gender
Female
Male
Clear selection
Date of birth (Must be over 18, or accompanied by an adult) If over the age of 18, and do feel the need to have a chaperone; by all means please do feel free to bring such a friend or relative to either sit in the massage room or to sit in our waiting room during the course of the massage. Yet, we do not have a chaperone available.
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MM
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DD
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YYYY
Email
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Your answer
Address
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Your answer
Phone number
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Your answer
Phone - Emergency
Your answer
Name of contact in case of emergency
Your answer
What is your occupation?
Your answer
Have you had a professional massage before? Yes or No. (If yes, please say how often you receive them or how long ago)
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Your answer
Do you have any difficulty lying down on your front, back, or side? Yes or No. (If yes, please explain why)
Your answer
Do you have any allergies to oils, lotions or treatments? Yes or No. (If yes, please explain)
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Your answer
Do you sit for long hours; at a workstation, behind a desk, in front of a computer, or driving? Yes or No. (If yes, please describe)
Your answer
Do you perform any repetitive movements at your work, sports, or hobbies? Yes or No. (If yes, please describe how)
Your answer
Are you currently under any medications? Yes or No. (If yes, please explain)
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Your answer
Are you pregnant? (If yes, how many months or weeks)
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Your answer
Is there anything else about your health history that you would think would be useful for a massage therapist to know? (This will be used to plan a safe and effective massage session for you)
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Your answer
Are you wearing contacts?
Yes
No
Clear selection
Are you wearing earings/or piercings?
Yes
No
Clear selection
Are you wearing earpiece?
Yes
No
Clear selection
Are you wearing hairpiece or extensions?
Yes
No
Clear selection
Will you be wearing any necklaces, bracelets, rings or any additional jewelry? Yes or No (If yes, we suggest to remove them before the session. Yet, if you will not remove them please indicate why not)
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Your answer
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