Patient Intake Form Therapeutic Touch Massage
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2Therapeutic Touch Massage LLC Intake Form
Name____________________________________________ Date of Birth __________
Address________________________________________________________________
Phone Number____________________
E-Mail______________________________
Emergency Contact and Phone Number _____________________________________
Occupation______________________________
How did you find out about us? __________________________________________
When was the last time you received a massage treatment? ____________
Have you had a Therapeutic Massage before?
Yes___
No____
What kind of massage are you looking for today or do you prefer?
Therapeutic___
Swedish___ Sports___
CranioSacral___
Reiki___
Have you had any surgeries, when & what for?
_____________________________________________________________________
Have you had any lymph nodes removed? If so please explain when & where.
______________________________________________________________________
Do you have any allergies?_____ If so, please list what you are allergic to & if you
are currently taking any medication.
_______________________________________________________________________
Are you currently on any specific medications, if so please list what you are
currently taking. Yes___ No___
________________________________________________________________________
Do you have any of the following medical conditions?
Fibromyalgia/Chronic Pain
____
Sprains/Strains ____
Cancer
____
Frequent headaches/Migraines
____
Carpal Tunnel
____
Diabetes ____
High/Low Blood Pressure
____
Arthritis
____
Warts
____
Congestive Heart Failure
____
Pregnant
____
TMJ
____
Autism/Asperger’s
____
Epilepsy
____
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