Massage Intake Form

Date
Date
1. Name: *
1. Name:
4. Type of pain:
Check all that apply
5. Does the pain radiate?
If you answer yes, please let us know where the pain radiates
8. Have you had any surgeries or accidents in the past 5 years?
11. Head/Neck
Do you presently suffer from any of the following? Check any that apply
12. Respiratory
Do you presently suffer from any of the following? Check any that apply
13. Cardiovascular
Do you presently suffer from any of the following? Check any that apply
heart attack date
stroke/CVA date
14. Skin
Do you presently suffer from any of the following? Check any that apply
15. Digestive/Uro-genital
Do you presently suffer from any of the following? Check any that apply
16. Other conditions
Do you presently suffer from any of the following? Check any that apply
17. Men
Do you presently suffer from the following? Check if applicable
18. Women
Do you presently suffer from the following? Check if applicable
Have you gone through menopause?
Are you pregnant?
When is your due date?
When is your due date?