Massage Health Intake Form

Name *

First Name

Last Name

DOB *

MM

DD

YYYY

Phone *

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Are you currently taking any medications? *

Yes

No

Do you have computer implants such as a pacemaker, insulin pump or spinal stimulator? *

Yes

No

Are you currently pregnant? *

Yes

No

Planning to be

Do you suffer from chronic pain?

Yes

No

Please indicate any of the following that apply to you:

Headaches / Migraines

Stress

Anxiety

Arthritis

Diabetes

Cancer

Joint Replacement

High/Low Blood Pressure

Neuropathy

Fibromyalgia

Digestion Issues

Stroke

Seizure

Heart Attack

Numbness

Kidney Dysfunction

Blood Clots

Depression

Joint Pain

Sinusitis

Dizziness

Fatigue

Abdominal Pain

Bloating

Hernia / Rupture

Varicose / Spider Veins

Osteoporosis

Skin Condition

Autoimmune Disorder

Other (please explain below)

Do you take in high amounts of any of the following?

Caffeine (4+ servings per day)

Nicotine (5+ cigarettes/vape breaks)

Alcohol (7+ drinks per week)

Fast Food (2+ times per week)

Water (8 ounces/half a gallon per day)

Have you had a professional massage before?

Yes

No

What type of pressure do you prefer?

Light

Medium

Deep

I'm unsure

Do you have any allergies or sensitivities? *

Yes

No

Do you now, or have you recently had any respiratory or flu symptoms? *

Yes

No

Have you had a fever in the last 24 hours? *

Yes

No

Have you been in contact with anyone in the last 14 days who has had COVID-19 symptoms? *

Yes

No

Would you prefer your practitioner to wear a mask during your appointment?

I have no preference, without is just fine.

Yes, please!