Intake

URL

This field is for validation purposes and should be left unchanged.

Tell us about yourself

Your Name(Required)

First Last

Your Address(Required)

Street Address Address Line 2 City ZIP Code

Your Email Address(Required)

Email Address Confirm Email Address

Your Phone(Required)

Emergency Contact(Required)

First Last

Emergency Contact Phone(Required)

Additional Comments or Concerns

Health Information

Current medical conditions, please describe below

Past injuries or surgeries, please describe below

Allergies (especially to oils, lotions, scents)

Medications (blood thinners, pain meds, etc.)

Skin conditions (psoriasis, eczema, infections)

Health continued, please select yes or no

Pregnancy status(Required)

Yes

Kidney Disease(Required)

Yes

Cancer(Required)

Yes

Bruise easily(Required)

Yes

Suffer from anxiety(Required)

Yes

Bleeding disorder or blood clots(Required)

Yes

Autoimmune Disorder(Required)

Yes

Fibromyalgia(Required)

Yes

Diabetes(Required)

Yes

Heart condition / Hypertension(Required)

Yes

Headaches(Required)

Yes

Neuropathy(Required)

Yes

Neurological Condition / Stroke(Required)

Yes

Osteoporosis(Required)

Yes

Osteoarthritis(Required)

Yes

Seizures(Required)

Yes

Sciatica(Required)

Yes

TMJ(Required)

Yes

Varicose Veins(Required)

Yes

PTSD / CPTSD(Required)

Yes

Depression(Required)

Yes

Vertigo or Dizziness(Required)

Yes

Lifestyle and Wellness

Activity level / exercise habits(Required)

Sleep quality(Required)

Stress level(Required)

Occupation(Required)

Have you ever had a massage?(Required)

Yes

Reason you are seeking massage

Relaxation

Specific Issue

Other

How much pressure do you prefer?

Massage Therapy Intake Form

Tell us about yourself

Health Information

Health continued, please select yes or no

Lifestyle and Wellness

Consent and Policies