Intake Form

Please complete and submit the below intake form prior to your massage appointment.

Date of Birth:

Referred by:

Do you currently experience any of the following conditions? If yes, please explain.

AllergiesNoYes
[group allergies-explain-group] [/group]
Pain/TendernessNoYes
[group pain-explain-group] [/group]
StressNoYes
[group stress-explain-group] [/group]
NumbnessNoYes
[group numbness-explain-group] [/group]
StiffnessNoYes
[group stiffness-explain-group] [/group]
SwellingNoYes
[group swelling-explain-group] [/group]

List all illnesses, injuries and health concerns you may have or have had in the past 3 years.

List medications and pain relievers you take:

What do you expect from today's massage?

Type of pressure preferred:

I have provided all known medical information. The general benefits of massage, possible contraindications and treatment procedure have been explained to me. I acknowledge that a massage is not a substitute for medical diagnoses and treatment. I hereby give my consent to receive treatment.