Massage Therapy Intake FormPlease fill out the form according to the best of your ability. You may fill out a form in person if you prefer. Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth MM DD YYYY Occupation Have you had a massage before? Yes No If so, approximately how long has it been since your last massage? What is the primary reason for your visit? Have you had any recent illnesses, injuries, or surgeries? If so, please explain: Are you currently under any medical treatment? If so, for what condition and with whom? Please list any medications, pain relievers, and/or supplements you are currently taking: Are you currently pregnant? Yes No If yes, how many weeks are you? Please select any of the symptoms or physical problems you are currently experiencing or have in the past: Allergies Cancer Dizziness Insomnia Sciatica Warts Arthritis HIV/AIDS Epilepsy Numbness Scoliosis Skin Rash Blood Pressure Issues Headache Speech Athlete's Foot Cardiovascular/Heart Issues Hearing Issues Poor Memory Weakness Herpes Diabetes Indigestion Respiratory Cut/Open Wount Virtual Signature * Your virtual signature indicates that you have provided all known medical treatment; understand that massage therapy is not a substitute for medical diagnosis and treatment; understand the massage therapy given here is for the purposes of stress reduction, relief from muscular tension or spasm, or for increasing circulation, and is not of a sexual nature. If you are undergoing any sort of cancer treatment, we will require a doctor's note before we can perform the massage. First Name Last Name Today's Date * MM DD YYYY Thank you! Your information will be kept confidential and will be made known only to your massage therapist for treatment purposes.
