Massage Intake

Full Name:

Date of Birth:

Gender:
MaleFemaleOther

Phone Number:

Email Address:

Emergency Contact (Name & Phone):

Do you have any medical conditions?
YesNo

If yes, please list:

Are you currently taking any medications?
YesNo

If yes, please list:

Do you have any allergies?
YesNo

If yes, please specify:

Do you have any specific areas of pain or discomfort?
YesNo

If yes, please describe:

On a scale of 1 to 10, how would you rate your pain?

What are your primary goals for today’s session?
RelaxationPain ReliefStress ReductionIncrease FlexibilityImprove CirculationInjury RecoveryOther

What type of pressure do you prefer during your massage?
LightMediumFirmDeep

Do you have any sensitivities to the type of oil or lotion used?
YesNo

If yes, please specify:

Signature:

Date: