* Massage Therapy Intake and Consent/Policies
Required Field
Personal Info
First Name
Last Name
Date of Birth (MM/DD/YYYY)
Occupation
Contact Info
Mobile Phone
Email
Source of Referral
Address
City
Country
Australia
Canada
Ireland
New Zealand
United Kingdom
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua And Barbuda
Argentina
Armenia
Aruba
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia, Plurinational State Of
Bosnia And Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
C?te D'Ivoire
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic Of The
Cook Islands
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island And Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Isle Of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People'S Republic Of
Korea, Republic Of
Kuwait
Kyrgyzstan
Lao People'S Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, The Former Yugoslav Republic Of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States Of
Moldova, Republic Of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Barth?lemy
Saint Helena, Ascension And Tristan Da Cunha
Saint Kitts And Nevis
Saint Lucia
Saint Martin
Saint Pierre And Miquelon
Saint Vincent And The Grenadines
Samoa
San Marino
Sao Tome And Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia And The South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard And Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province Of China
Tajikistan
Tanzania, United Republic Of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks And Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela, Bolivarian Republic Of
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis And Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Province / State
Postal / Zip Code
Emergency Contact
Emergency Contact
Emergency Phone
Relationship
Doctor
Doctor's Name
Doctor's Phone
Doctor's Address
Other
Height & Weight
Characters:
0
/255
Other
Primary Complaint ( or just say relaxation)
Characters:
0
/255
Describe how and when the pain started
Characters:
0
/255
Describe the Pain (Aching, Cramping, Sharp, Shooting, Numbness, Tingling, Stabbing, Tender, Tightness, Tension, etc.)
Characters:
0
/255
What makes it worse?
Characters:
0
/255
What makes it better?
Characters:
0
/255
Current Treatment/Remedies
Characters:
0
/255
Past Treatments
Characters:
0
/255
Date of last massage
Characters:
0
/255
On a scale of 1-10, what is your pain right now?
Characters:
0
/255
What kind of pressure do you prefer?
Characters:
0
/255
Recreational Activities
Characters:
0
/255
Occupational Activities
Characters:
0
/255
Massage Goals
Relaxation
Characters:
0
/255
Improve Range of Motion
Characters:
0
/255
Pain Relief
Characters:
0
/255
Tension Relief
Characters:
0
/255
To Start a Regular Massage Plan
Characters:
0
/255
Therapeutic Massage
Characters:
0
/255
Other
Characters:
0
/255
Conditions
Area of Complaint
Left Side of Neck
Characters:
0
/255
Right Side of Neck
Characters:
0
/255
Left Side of Upper Back
Characters:
0
/255
Right Side of Upper Back
Characters:
0
/255
Left Side of Mid Back
Characters:
0
/255
Right Side of Mid Back
Characters:
0
/255
Left Side of Low Back
Characters:
0
/255
Right Side of Low Back
Characters:
0
/255
Chest
Characters:
0
/255
Abdomen
Characters:
0
/255
Left Arm
Characters:
0
/255
Right Arm
Characters:
0
/255
Left Shoulder
Characters:
0
/255
Right Shoulder
Characters:
0
/255
Left Elbow
Characters:
0
/255
Right Elbow
Characters:
0
/255
Left Wrist
Characters:
0
/255
Right Wrist
Characters:
0
/255
Left Hand
Characters:
0
/255
Right Hand
Characters:
0
/255
Left Leg
Characters:
0
/255
Right Leg
Characters:
0
/255
Left Hip
Characters:
0
/255
Right Hip
Characters:
0
/255
Left Knee
Characters:
0
/255
Right Knee
Characters:
0
/255
Left Ankle
Characters:
0
/255
Right Ankle
Characters:
0
/255
Left Foot
Characters:
0
/255
Right Foot
Characters:
0
/255
Circulatory
Blood Clots
Characters:
0
/255
Heart Disease
Characters:
0
/255
Aneurysm
Characters:
0
/255
Congestive Heart Failure
Characters:
0
/255
Phlebitis
Characters:
0
/255
Varicose Veins
Characters:
0
/255
Heart Attack
Characters:
0
/255
Blood Pressure
Characters:
0
/255
Lymphedema
Characters:
0
/255
Thrombosis/Embolism
Characters:
0
/255
Swelling
High Blood Pressure
Characters:
0
/255
Low Blood Pressure
Characters:
0
/255
Cold Hands
Characters:
0
/255
Cold Feet
Characters:
0
/255
Other, or anything not listed
Characters:
0
/255
Digestive
Constipation
Characters:
0
/255
Irritable Bowel Syndrome
Characters:
0
/255
Low Blood Sugar/Hypoglycemia
Characters:
0
/255
Diabetes
Characters:
0
/255
Crohn's Disease
Characters:
0
/255
Diverticulitis
Characters:
0
/255
Ulcerative Colitis
Characters:
0
/255
Other, or anything not listed
Characters:
0
/255
Headaches
Migraines
Characters:
0
/255
Headaches
Characters:
0
/255
Sinus
Characters:
0
/255
Chronic Daily Headache
Characters:
0
/255
Tension
Characters:
0
/255
Other, or anything not listed
Characters:
0
/255
Nervous System
Sciatica
Characters:
0
/255
Multiple Sclerosis
Characters:
0
/255
Stroke
Characters:
0
/255
Epilepsy
Characters:
0
/255
Seisure
Characters:
0
/255
Fainting
Characters:
0
/255
Seizure Disorder
Characters:
0
/255
Vertebral and Spinal Cord Injury
Characters:
0
/255
Cerebral Palsy
Characters:
0
/255
Dizziness
Characters:
0
/255
Other, or anything not listed
Characters:
0
/255
Musculoskeletal
Muscle Pain
Characters:
0
/255
Muscle Weakness
Characters:
0
/255
Strain/Sprain
Characters:
0
/255
Joint Issue
Characters:
0
/255
Foot Issue
Characters:
0
/255
Broken Bones
Characters:
0
/255
Neck Injury
Characters:
0
/255
Osteoporosis
Characters:
0
/255
Tendonitis
Characters:
0
/255
Arthritis
Characters:
0
/255
Herniated or Bulging Disc (Where and what stage?)
Characters:
0
/255
Ankylosing Spondylitis
Characters:
0
/255
Coccyx Injury
Characters:
0
/255
Scoliosis
Characters:
0
/255
Spondylolisthesis
Characters:
0
/255
Stenosis
Characters:
0
/255
Degenerative Disc Disease
Characters:
0
/255
Laminectomy
Characters:
0
/255
Spinal Rod
Characters:
0
/255
Fusion
Characters:
0
/255
Screws
Characters:
0
/255
Artificial Joints / Special Equipment
Characters:
0
/255
Dislocation
Characters:
0
/255
Tendonitis/Bursitis
Characters:
0
/255
Fracture
Characters:
0
/255
Other, or anything not listed
Characters:
0
/255
Respiratory
Respiratory Conditions
Characters:
0
/255
Sinus Congestion
Characters:
0
/255
Asthma
Characters:
0
/255
Other, or anything not listed
Characters:
0
/255
Skin Issues
Athlete's Foot
Characters:
0
/255
Dry Skin
Characters:
0
/255
Burn
Characters:
0
/255
Non-Surgical Scars
Characters:
0
/255
Sensitive Skin
Characters:
0
/255
Skin Irritations
Characters:
0
/255
Herpes
Characters:
0
/255
Psoriasis
Characters:
0
/255
Cellulitis
Characters:
0
/255
Rash
Characters:
0
/255
Bruise Easily
Characters:
0
/255
Contagious Disease
Characters:
0
/255
Skin Irritations
Characters:
0
/255
Plantar's Wart
Characters:
0
/255
Other, or anything not listed
Characters:
0
/255
Reproductive
Pregnancy (*Barefoot Massage will not be performed if you are pregnant)
Characters:
0
/255
Trying to Conceive
Characters:
0
/255
Number of Previous Pregnancies/Births
Characters:
0
/255
Previous C-Section
Characters:
0
/255
Nursing
Characters:
0
/255
Premenstrual Syndrome
Characters:
0
/255
Other, or anything not listed
Characters:
0
/255
TMJ (Jaw)
Ear Stuffiness
Characters:
0
/255
Ear Blockage
Characters:
0
/255
Ear Pressure
Characters:
0
/255
Jaw Pain
Characters:
0
/255
Locking
Characters:
0
/255
Clenching
Characters:
0
/255
Grinding
Characters:
0
/255
Difficulty Opening Jaw
Characters:
0
/255
Clicking
Characters:
0
/255
Difficulty Chewing
Characters:
0
/255
Other, or anything not listed
Characters:
0
/255
Other
Do you have any allergies? If yes, please Explain
I wear Contact Lenses
Characters:
0
/255
Cancer
Characters:
0
/255
Are you a Smoker?
Characters:
0
/255
Augmentation/Implants: breast, gluteal, cheeks, lips, calves, etc.
Characters:
0
/255
Menopause
Characters:
0
/255
Abdominal Hernia
Characters:
0
/255
Eye/Optical Issue
Characters:
0
/255
Recent Lasik Surgery (past 72 hours)
Characters:
0
/255
Insomnia
Characters:
0
/255
Injections or Shots
Characters:
0
/255
Amputation
Characters:
0
/255
Depression
Characters:
0
/255
Claustrophobia
Characters:
0
/255
PTSD
Characters:
0
/255
Other Medical Conditions
Characters:
0
/255
Other Diagnosed Diseases
Characters:
0
/255
Other (anything not listed)
Characters:
0
/255
Medications
Medications, Vitamins/Herbs (include reason for taking)
Characters:
0
/255
Significant Injuries
Significant INJURIES during lifetime (give year)
Characters:
0
/255
Surgeries
Do you have any upcoming medical procedures? If yes, please Explain
Characters:
0
/255
All SURGERIES (give year)
Characters:
0
/255
Have you had surgery within the last 6 WEEKS (Please provide a note from your Doctor allowing you to receive massage)
Characters:
0
/255
Review & Agree
Client Consent **Please Read**
(Review Required)
You need to review and accept this before submitting
Signature
×
Submit Form
×