Massage And Bodywork Intake Form
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2Massage and Bodywork Intake Form
Client Information
Name
Date
Day Phone (
)
Street
City
State
Zip
Eve Phone (
)
Occupation
Date of Birth
Emergency Contact Name and Phone
(
)
Referred By
Email
Massage History / Session Information
Have you ever received a professional massage?
Yes
No
Date of last massage
What result do you want from your massage sessions?
List any exercise activities. Include frequency:
Are you currently under the care of a health care practitioner?
Yes
No
If yes, specify purpose:
List current medications and purpose:
Previous History (Include year and treatment received)
Injuries/accidents/illnesses still affecting you:
Surgeries:
Please mark any of the following that you now have or have had.
Musculoskeletal
Circulatory
Bone or joint disease
Heart Condition
Tendonitis / Bursitis
Phlebitis / Varicose Veins
Arthritis / Gout
Blood Clots
Jaw pain (TMJ)
High / Low Blood Pressure
Lupus
Lymphedema
Spinal Problems
Thrombosis / Embolism
Other : _____________________________
Other : _____________________________
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Parent category: Business