Massage Intake Form - Providence Apothecary
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1
2Massage
I ntake
F orm
-‐
C ONFIDENTIAL
I NFORMATION
WELCOME!
W e
w ould
l ike
t o
m ake
y our
a ppointment
a s
p leasant
a nd
c omfortable
a s
possible.
I f,
a t
a ny
t ime,
y ou
h ave
q uestions
r egarding
y our
s ession,
p lease
l et
u s
k now.
Name
_ _____________________________________________________________
D ate
o f
b irth
_ ____/_____/__________
Address____________________________________
C ity
_ _________________________
S tate
_ _______
Z ip
_ __________
Home
P hone
( _____)-‐_________________
W ork
P hone
( _____)-‐_________________
E-‐mail
a ddress
_ _________________________________________
N ewsletter
s ignup?
( circle
o ne):
Y es
N o
How
d id
y ou
h ear
a bout
u s?
_ ____________________________________________
Occupation
_ ______________________________________
Have
y ou
e ver
r eceived
m assage
t herapy?
( circle
o ne):
Y es
N o
Are
y ou
c urrently
t aking
a ny
m edications?
( circle
o ne):
Y es
N o
If
y es,
p lease
l ist
n ame
a nd
r eason
f or
m edications:
_ ___________________________________________________
_______________________________________________________________________________________________________________
Are
y ou
c urrently
s eeing
a
h ealthcare
p rofessional?
( circle
o ne):
Y es
N o
If
y es,
p lease
l ist
n ames
a nd
r eason/treatment:
_ _______________________________________________________
_______________________________________________________________________________________________________________
Please
r eview
t his
l ist
a nd
c heck
t hose
c onditions
t hat
h ave
a ffected
y our
h ealth
e ither
c urrently
or
i n
t he
p ast.
P lace
a
c heck
m ark
n ext
t o
t he
c ondition.
_____arthritis
_____diabetes
_____
d epression,
p anic
d isorder
c ondition
_____blood
c lots
_____
d iverticulitis
_____broken/dislocated
b ones
_____
h eadaches
_____bruise
e asily
_____
h eart
c onditions
_____cancer
_____
b ack
p roblems
_____chronic
p ain
_____
h igh
b lood
p ressure
_____constipation/diarrhea
_____
i nsomnia
_____auto-‐immune
c ondition*
_____
m uscle
s train/sprain
_____hepatitis
( A,
B ,
C ,
o ther)
_____
p regnancy
_____skin
c onditions
_____
s coliosis
_____stroke
_____
s eizures
_____surgery
_____
w hiplash
_____TMJ
d isorder
_____
c hemical
d ependency
( alcohol,
d rugs)
(*AIDS,
f ibromyalgia,
c hronic
f atigue,
l upus,
e tc.)
If
a ny
o f
t he
a bove
n eeds
t o
b e
d etailed
o r
i f
t here
i s
a nything
e lse
t o
s hare,
p lease
d o
s o:
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
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