Massage Intake Form

Massage Intake Form

Name: __________________________________________ Date: ______________

Address: ______________________________________________________________

Phone: ___________________________ Cell: _______________________________

Occupation: _________________________________

Have you ever received a professional massage? _____ Yes ______ No

Are you pregnant? _____ Yes ______ No

Are you allergic or sensitive to any oils (essential oils, nut oils, scents)?

If yes, please list: ____________________________________________________

Do you have any difficulty lying on your front, back, or side?

If yes, please explain: _______________________________________________

Do you perform any repetitive movement in your work, sports, or hobby?

If yes, please describe: _______________________________________________

Are you currently seeing a healthcare professional? ______Yes ______ No

If yes, please list names and reason/treatment: __________________________ ________________________________________________________________________

Are you wearing: _____contact lenses ______hearing aid ______hairpiece

Please review this list and check those conditions that have affected your health either recently or in the past. Place a check mark next to the condition.

___ arthritis ___ diabetes

___ blood clots ___ broken/dislocated bones

___ bruise easily ___ cancer

___ chronic pain ___ constipation/diarrhea

___ auto-immune condition* ___ hepatitis (A, B, C, other)

___ skin conditions ___ stroke

___ surgery ___ TMJ disorder

___ depression ___ headaches

___ heart conditions...