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Massage Intake Form

Massage Intake Form

Personal Information

Medical Information

Are you taking any medications?
No
Yes
Are you currently pregnant?
No
Yes
Do you suffer from chronic pain?
No
Yes
Have you had any orthopedic injuries?
No
Yes
Please indicate any of the following that apply to you.

Massage Information

Have you had a professional massage before?
No
Yes
What type of massage are you seeking?
Relaxation
Therapeutic/Deep Tissue
What pressure do you prefer?
Light
Medium
Deep
Do you have any allergies or sensitivities?
No
Yes
Are there any areas (feet, face, abdomen, etc.) you do not want massaged?
No
Yes
Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.
Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.
Human Body Drawing
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