MASSAGE - Intake Form

Please complete this massage intake before your appointment so your practitioner can understand your health history, goals, and any areas of concern.

First name

Middle name

Last name

What are your health concerns and goals?

Allergies

Vitamins/supplements and reason for taking

Medications and reason for taking

Hospitalizations

Have you had any surgeries?

Yes

Are you currently pregnant or attempting to become pregnant?

Yes

Do you suffer from any chronic pain? If yes, please describe this pain.

Is there anything that aggravates or alleviates your discomfort?

Please select any health conditions that apply

Cancer

Headaches/Migraines

Arthritis

Diabetes

Joint Replacement

High/Low Blood Pressure

Neuropathy

Fibromyalgia

Stroke

Heart Attack

Kidney Dysfunction

Blood Clots

Numbness/Tingling

Sprains or Strains

Sweats easily

Hot or Cold easily

I have answered truthfully and to the best of my knowledge

Created with

MASSAGE - Intake Form

Please complete this massage intake before your appointment so your practitioner can understand your health history, goals, and any areas of concern.

First name

Middle name

Last name

What are your health concerns and goals?

Allergies

Vitamins/supplements and reason for taking

Medications and reason for taking

Hospitalizations

Have you had any surgeries?

Yes

Are you currently pregnant or attempting to become pregnant?

Yes

Do you suffer from any chronic pain? If yes, please describe this pain.

Is there anything that aggravates or alleviates your discomfort?

Please select any health conditions that apply

Cancer

Headaches/Migraines

Arthritis

Diabetes

Joint Replacement

High/Low Blood Pressure

Neuropathy

Fibromyalgia

Stroke

Heart Attack

Kidney Dysfunction

Blood Clots

Numbness/Tingling

Sprains or Strains

Sweats easily

Hot or Cold easily

I have answered truthfully and to the best of my knowledge

Created with

MASSAGE - Intake Form