Massage Therapy Intake
Required Field
Personal Info
First Name
Last Name
Date of Birth (MM/DD/YYYY)
Gender
Male
Female
Identify as
Identify as
Occupation
Contact Info
Mobile Phone
Home 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
Kosovo
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
Injuries
Injury
Add Another Injury
Surgeries
Surgery
Add Another Surgery
Medications
Medication
Add Another Medication
Area of Complaint
Please list any problem areas (ex: left low back tightness, right shoulder pain, achy knees)
Characters:
0
/255
Massage Goals
Increase Well-Being
Injury Rehabilitation
Pain Relief
Positive Reinforcement
Stress Relief
Improve Symptoms
Light Pressure Preferred
Medium Pressure Preferred
Deep Pressure Preferred
Date of Last Massage
Characters:
0
/255
Massage Frequency
Characters:
0
/255
Other
Characters:
0
/255
Conditions
Musculoskeletal
Osteoporosis
Characters:
0
/255
Arthritis
Characters:
0
/255
Fibromyalgia
Characters:
0
/255
Whiplash
Characters:
0
/255
Dislocation
Characters:
0
/255
Baker's Cyst
Characters:
0
/255
Jaw Pain (TMJD)
Characters:
0
/255
Carpal Tunnel Syndrome
Characters:
0
/255
Osteoarthritis
Characters:
0
/255
Tendonitis/Bursitis
Characters:
0
/255
Gout
Characters:
0
/255
Artificial Joints/Special Equipment
Characters:
0
/255
Plantar Fasciitis
Characters:
0
/255
Scleroderma
Characters:
0
/255
Scoliosis
Characters:
0
/255
Amyotrophic Lateral Sclerosis (ALS)
Characters:
0
/255
Adhesive Capsulitis
Characters:
0
/255
Other Musculoskeletal
Characters:
0
/255
Neurological
Tingling
Characters:
0
/255
Stabbing
Characters:
0
/255
Loss of Sensation
Characters:
0
/255
Numbness
Characters:
0
/255
Burning
Characters:
0
/255
Multiple Sclerosis
Characters:
0
/255
Sciatic Pain
Characters:
0
/255
Seizure Disorder
Characters:
0
/255
Vertebral and Spinal Cord Injury
Characters:
0
/255
Dizziness
Characters:
0
/255
Parkinsons
Characters:
0
/255
Peripheral Neuropathy
Characters:
0
/255
Cardiovascular
Varicose Veins
Characters:
0
/255
Heart Attack
Characters:
0
/255
Blood Clots
Characters:
0
/255
Peripheral Vascular Disease (PVD)
Characters:
0
/255
Aneurysm
Characters:
0
/255
Lymphedema
Characters:
0
/255
Pacemaker
Characters:
0
/255
Raynaud Disease
Characters:
0
/255
Stroke
Characters:
0
/255
High Blood Pressure
Characters:
0
/255
Low Blood Pressure
Characters:
0
/255
Chronic Venous Insufficiency
Characters:
0
/255
Other Cardiovascular
Characters:
0
/255
Skin
Acne
Characters:
0
/255
Athlete's Foot
Characters:
0
/255
Psoriasis
Characters:
0
/255
Eczema
Characters:
0
/255
Pigmentary Disorder
Characters:
0
/255
Urticaria/Hives
Characters:
0
/255
Bruise Easily
Characters:
0
/255
Allergic Dermatosis
Characters:
0
/255
Rash
Characters:
0
/255
Herpes
Characters:
0
/255
Botox/Fillers
Characters:
0
/255
Rosacea
Characters:
0
/255
Chemical Burn
Characters:
0
/255
UV Burn
Characters:
0
/255
Hypersensitive Reactions
Characters:
0
/255
Melanoma/Carcinoma
Characters:
0
/255
Infectious Skin Conditions
Characters:
0
/255
Plantar's Wart
Characters:
0
/255
Other Skin Conditions
Characters:
0
/255
Blood
Blood Thinner Medication
Characters:
0
/255
Thrombosis/DVT
Characters:
0
/255
Anemia
Characters:
0
/255
Hepatitis
Characters:
0
/255
Immune
Allergies
Characters:
0
/255
Anaphylaxis
Characters:
0
/255
Rheumatoid Arthritis
Characters:
0
/255
Lupus
Characters:
0
/255
Lymphoma
Characters:
0
/255
Leukemia
Characters:
0
/255
HIV/Aids
Characters:
0
/255
Weakened Immune Function
Characters:
0
/255
Reproductive
Ovarian Cysts/Tumors
Characters:
0
/255
Pelvic Inflammatory Disease
Characters:
0
/255
Pregnancy
Characters:
0
/255
Ectopic Pregnancy
Characters:
0
/255
Gastrointestinal
Constipation
Characters:
0
/255
Irritable Bowel Syndrome
Characters:
0
/255
Intestinal Gas/Bloating
Characters:
0
/255
Acid Reflux
Characters:
0
/255
Abdominal Hernia
Characters:
0
/255
Adaptive Aids
Characters:
0
/255
Respiratory
Chronic Cough
Characters:
0
/255
Asthma
Characters:
0
/255
Emphysema
Characters:
0
/255
COPD
Characters:
0
/255
Infectious Respiratory Conditions
Characters:
0
/255
Hearing
Meniere Disease
Characters:
0
/255
Motion Sickness
Characters:
0
/255
Tinnitus
Characters:
0
/255
Vertigo
Characters:
0
/255
Hearing Loss
Characters:
0
/255
Kidney
Urinary Incontinence
Characters:
0
/255
Kidney Disease
Characters:
0
/255
Electrolyte Imbalance
Characters:
0
/255
Kidney Stones
Characters:
0
/255
Endocrine
Diabetes
Characters:
0
/255
Blood Sugar Managed?
Characters:
0
/255
Hyperthyroidism
Characters:
0
/255
Hypothyroidism
Characters:
0
/255
Oncology
Cancer Type
Characters:
0
/255
Date of Diagnosis
Characters:
0
/255
Location
Characters:
0
/255
Status
Characters:
0
/255
Treatment: Surgery
Characters:
0
/255
Date of Surgery
Characters:
0
/255
Lymph Nodes Removed
Characters:
0
/255
Side Effects of Surgery
Characters:
0
/255
Reconstruction Date
Characters:
0
/255
Treatment: Chemotherapy
Characters:
0
/255
Number of Chemo Treatments
Characters:
0
/255
Area of Radiation
Characters:
0
/255
Nodes Irradiated
Characters:
0
/255
Side Effects of Radiation
Characters:
0
/255
Other Treatments
Characters:
0
/255
Medical devices
Characters:
0
/255
Nausea
Characters:
0
/255
Vomiting
Characters:
0
/255
Mouth Sores
Characters:
0
/255
Weight Loss
Characters:
0
/255
Weight Gain
Characters:
0
/255
Bone Pain
Characters:
0
/255
Adhesions
Characters:
0
/255
Incision
Characters:
0
/255
Pressure Sensitivity
Characters:
0
/255
Loss of Movement
Characters:
0
/255
Abnormal Skin Sensation
Characters:
0
/255
Memory Problems
Characters:
0
/255
Edema
Characters:
0
/255
Low Platelet
Characters:
0
/255
Low White Count
Characters:
0
/255
Blood Clot
Characters:
0
/255
Excessively Warm/Cold
Characters:
0
/255
Lymphedema
Characters:
0
/255
Dry Skin
Characters:
0
/255
Fragile Skin
Characters:
0
/255
Radiation Skin Reaction
Characters:
0
/255
Fatigue
Characters:
0
/255
Systemic Infection
Characters:
0
/255
Infectious condition
Characters:
0
/255
Current Tumor
Characters:
0
/255
Enlarged Lymph Nodes
Characters:
0
/255
Radioactivity
Characters:
0
/255
Miscellaneous
Visually Impaired
Characters:
0
/255
Sensitivities to Scents/Essential Oils
Characters:
0
/255
Surgical Pins, Wire, or Implants
Characters:
0
/255
Benign Cysts/Tumors
Characters:
0
/255
Anxiety
Characters:
0
/255
Depression
Characters:
0
/255
PTSD
Characters:
0
/255
Claustrophobia
Characters:
0
/255
Agoraphobia
Characters:
0
/255
Other Mental Health
Characters:
0
/255
Sleep Disorder/Dysfunction
Characters:
0
/255
Neurodivergent
Characters:
0
/255
Loss of Balance
Characters:
0
/255
Other Medical Conditions
Characters:
0
/255
Other Diagnosed Diseases
Characters:
0
/255
Review & Agree
Informed Consent / Liability Waiver (COVID-19)
(Review Required)
You need to review and accept this before submitting
Informed Consent / Policies & Agreements
(Review Required)
You need to review and accept this before submitting
Signature
×
Submit Form
×