Massage Client Intake 07/24

Required Field

Personal Info

First Name

Last Name

Pronouns

Date of Birth (MM/DD/YYYY)

Gender

Occupation

Contact Info

Mobile Phone

Source of Referral

Address

City

Country

Province / State

Postal / Zip Code

Emergency Contact

Emergency Phone

Relationship

Health History

Primary Complaint or Reason for Seeking Massage

Current Treatment (Self & Other Practitioners)

Past Treatment (Self & Other Practitioners)

Please List All Health Conditions (& provide any pertinent details)

Please List Any Current, Relevant or Historic Major Injuries

Please List All Prior & Upcoming Surgeries with Approximate Dates

Are You Taking Any Medications for Any Reason? (Please describe)

Do you have any allergies? If so, please describe.

Anything Else You'd Like Sarah to Know?

Review & Agree

Informed Consent (Review Required)

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