Massage Intake Form

First Name *

Last Name *

Nickname

Date of Birth *

format must be xx/xx/xxxx

Email Address *

Phone Number *

Address

Zip Code *

Occupation

Emergency Contact Name

Emergency Contact Phone Number

Gender

What pronouns do you use?

e.g. she/her, he/him, they/them, etc

How did you hear about us?

Who referred you specifically?

Are you currently experiencing any of the following conditions?

Please mark conditions which apply to your present health or with which you have a significant history:

Please describe current conditions and past surgeries, accidents, injuries, concussions, fractures, major illnesses, or current medical conditions.

Please select any areas where you are currently or habitually experiencing pain or tension:

Please add any details about affected areas:

Do you have any known allergies or chemical sensitivities?

Yes

No

What are you allergic or sensitive to?

Are you currently pregnant or attempting to conceive?

Yes

No

Planning

If pregnant, when are you due?