Massage Intake Form - Fitness for the Soul

Personal Information

Name*

First Last

Phone*

Email*

Enter Email Confirm Email

Date of Birth*

Address*

Street Address Address Line 2 City State ZIP Code

Occupation

Employer

Primary Physician

Emergency Contact

Relationship

Phone

How did you hear about us?

Medical Information

Are you taking any medication?*

Yes
No

If yes, please list name and use:

Are you currently pregnant?*

Yes
No

If yes, how far along?

Any high risk factors?

Do you suffer from chronic pain?*

Yes
No

If yes, please explain:

What makes it better?

What makes it worse?

Have you had an orthopedic injuries?*

Yes
No

If yes, please explain:

Please indicate any of the following that apply to you:

Explain any conditions you have marked:

Massage Information

Have you had a professional massage before?*

Yes
No

What type of massage are you seeking?*

Relaxation
Therapeutic/Deep Tissue
Other

What type of pressure do you prefer?*

Light
Medium
Deep

Do you have any allergies or sensitivities?*

Yes
No

Please explain:

Are there any areas you do not want massaged?*

Yes
No

Please explain:

What are your goals for this treatment session?

Consent*

I agree to the following:

I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time. 24 hour notice on all cancellations is required or a 50% of service fee is applied. If a no call/ no show occurs a 100% service fee is applied. Fees will be charged to your credit card on file. Be courteous to your therapist and give notice.