Massage Intake Form
Name
*
First Name
Last Name
Today's Date
*
-
Month
-
Day
Year
Date
Which massage therapist are you seeing?
*
Shannon McCluskey
Kylee Croasmun
Gender
*
Male
Female
Prefer not to identify
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Did someone refer you to us?
*
Yes
No
Awesome! Who referred you?
*
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone
*
Please enter a valid phone number.
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Next
Physician/Health Care Provider Name
*
Physician/Health Care Provider Phone
*
Please enter a valid phone number.
Have you ever received professional massage/bodywork before?
*
Yes
No
How recently?
*
What kind of pressure do you prefer?
*
Light
Medium
Firm
What are your goals/expected outcomes for receiving massage/bodywork? what areas of the body would you like to focus on?
*
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Next
Do these symptoms interfere with your daily living (sleep, exercise, work, childcare)?
*
Yes
No
If yes, please explain how they affect you.
*
Are you taking any medications?
*
Yes
No
Please list any medications that you are taking.
*
Have you had any injuries, procedures, illnesses, or conditions currently or over the past two years that may influence massage treatments?
*
Yes
No
If yes, please describe and include dates.
*
Back
Next
Please indicate conditions that you have or have had in the past. Please explain in detail, including treatments received.
*
N/A
Current
Past
Details and Treatment Received
Muscle or Joint Pain/stiffness
Numbness or tingling
Swelling
Bruise Easily
High/low blood pressure
Stroke, heart attack
Varicose veins
Shortness of breath, asthma
Cancer
Neurological (MS, Parkinson's Chronic Pain)
Epilepsy, seizures
Headaches, migraines
Dizziness, ringing in the ears
Digestive conditions (Chron's, IBS)
Gas, bloating, constipation
Kidney disease, infection
Arthritis (rheumatoid, osteoarthritis)
Osteoporosis, degenerative spine/disk
Scoliosis
Broken bones
Allergies
Diabetes
Endocrine/thyroid conditions
Depression, anxiety
Memory loss, confusion, easy overwhelmed.
Any additional comments?
Signature
*
Today's Date
*
-
Month
-
Day
Year
Date
Submit
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