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Massage Intake Form
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* Indicates required question
Name:
*
Your answer
Date of Appointment:
*
MM
/
DD
/
YYYY
Address:
*
Your answer
Phone Number:
*
Your answer
Preferred Email:
*
Your answer
Date of Birth:
*
MM
/
DD
/
YYYY
Sex:
*
Male
Female
Prefer not to say
Other:
Height:
*
Your answer
Weight:
*
Your answer
Exercise Frequency/Types
Your answer
Do you smoke?
Yes
No
Clear selection
How much water do you drink per day?
Your answer
What medications are you currently taking
*
Your answer
Previous complaints/surgery/medications
*
Your answer
What is your major complaint?
Your answer
Have you received massage therapy before?
Yes
No
Clear selection
Goals for the massage:
*
Relaxation
Rehabilitation
High Activity Recovery/Maintenance
Required
Preferred Type of Touch
*
Light
Heavy
Deep
Meditative
Invigorating
Trigger Point
Required
Do you have any of the following
Sunburn
Cuts/Burns/Bruises
Inflammation
Irritated Skin Rash
Poison Ivy
Heart Disease
High Blood Pressure
Low Blood Pressure
Diabetes
Arteriosclerosis
Varicose Veins
Severe Pain
Arthritis
Hernia
Musculoskeletal Problems
Headache
Dizziness
Epilepsy
Depression
Cold or Flu-like Symptoms
Pregancy
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