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New Client Intake Form

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MASSAGE THERAPY SERVICES

Your Information

PERSONAL INFORMATION

First Name*

Last Name*

Email*

Street Address, House number etc*

Landmark, Floor, c/o

City*

Country*

State/Province*

Zip/Postal Code*

+ 4

DOB

Emergency Contact

Relationship

Phone

How Did You Hear About Us?

MEDICAL INFORMATION

Are you taking any medications?

Yes No

If yes, please list:

Are you currently pregnant?

Yes No

If yes, how far along?

Any high risk factors?

Do you suffer from chronic pain?

Yes No

If yes, please explain

What makes it better?

What makes it worse?

Do you currently have any injuries?

Yes No

If yes, please explain

MASSAGE INFORMATION

Have you had a professional massage before?

Yes No

What type of massage are you seeking?

Relaxation Therapeutic/Deep Tissue

Other

What pressure do you prefer?

Light Medium Deep

Do you have any allergies or sensitivities?

Yes No

Please explain

Are there any areas you don't want massaged?

Yes No

Please Mentioned any areas of discomfort or tenderness:

Please explain any conditions or areas of discomfort you have marked above:

I have completed this form to the best of my ability, and I agree to inform my therapist if any of the above information changes

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Signature

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Date