Massage Therapy

Client Intake Form

Name *

Name * *

Phone *

Phone * *

Date of Birth *

Date of Birth * *

Please answer the questions below

Have you received massage therapy before? *

Have you received massage therapy before? * *

YesNo

Are you currently pregnant? *

Are you currently pregnant? * *

YesNo

Please mark any of the following conditions you currently have

CancerHeadaches / MigrainesFibromyalgiaArthritisKidney DysfunctionStrokeDiabetesRecent Cold / FluSprains or StrainsAlcohol within 24hrsNumbnessHeart AttackPhlebitisHigh Blood PressureVaricose VeinsAcute PainChronic PainRecent SurgeryOpen WoundsOsteoporosis

Additional notes, allergies or sensitivities

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