Massage Therapy Intake Form CONFIDENTIAL INFORMATION Today's Date Date Format: DD slash MM slash YYYY Name* First Last Date of Birth* Date Format: DD slash MM slash YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Phone (Home)Phone (Work/Cell)Email OccupationHeightPlease enter a number from 1 to 100.WeightEmergency contact name & numberReferred by:Are you currently in pain or experiencing any discomfort? If so, please briefly explain and indicate those areas belowDescribe any chronic pain/tensionWhat makes it better?What makes it worse?Are you currently under the care of a physician, chiropractor or alternative medicine practitioner? If yes, what are you being treated for?Please list any medications (prescription or non-prescription), vitamins and supplements you are currently taking:Are you currently receiving any other body or energy therapies?If yes, what for?What specific areas would you like for me to focus on or stay away from?Are there any areas you do NOT like massaged (i.e. feet, stomach, head, face)?What do you hope to accomplish with this massage? (i.e. relaxation, decrease back pain, increase flexibility, etc.)How frequently and for how long do you exercise and what do you do? Include sports, Pilates, yoga, gardening and/or other physical activities:How many hours of sleep do you receive each night (approximately)?What is your sleeping position?Check one:Are you right-handedAre you left-handedWhat is your daily intake of:Water:Caffeine:Alcohol:Please check any of the following that apply to youin the past or present:HeadachesType: Past Present Pins and Needles in arms, legs, Hands or feet Past Present Asthma Past Present Neurological problems Past Present Cold Hands/feet Past Present Spinal Problems Past Present Swollen ankles Past Present Herniated/Bulging Discs Past Present Sinus Conditions Past Present Osteoarthritis Past Present Frequent Colds Past Present Arthritis Past Present Allergies (specify above) Past Present Anxiety Past Present Loss of smell/taste Past Present Depression/Panic Past Present Skin Conditions Past Present Sleep Disturbance Past Present Painful/Swollen Joints Past Present Loss of Memory Past Present Auto-immune disorder Past Present Whiplash Past Present Cancer Past Present Bruise Easily Past Present Varicose Veins Past Present Constipation/Diarrhea Past Present Blood Clots/DVT Past Present Contact Lenses Past Present Heart Problems Past Present Dentures/Partials Past Present Pacemaker Past Present Hemorrhoids Past Present High/Low BP Past Present Artificial/Missing limbs Past Present Diabetes Past Present Muscular Tension Past Present Epilepsy or Seizures Past Present Sciatica Past Present Fainting Spells Past Present Further explanation of any condition or other information:The following sometimes occurs during massage; they are normal responses to relaxation. Trust your body to express what it needs: Need to move or change positions Sighing, yawning, change in breath Stomach gurgling Emotional feelings and/or expressions Movement of intestinal gas Energy shifts Falling asleep Memories I understand the treatment here is not a replacement for medical care. As such, the therapist/practitioner does not prescribe medical treatment of pharmaceuticals, nor does he/she perform any spinal manipulations I understand that the treatment is not a substitute of medical treatments and/or diagnosis and it is recommended that I see a qualified professional for any physical or mental conditions that I may have. I have stated all my known conditions and take it upon myself to keep the therapist/practitioner updated on my health. I understand that payment is due at the time of treatment unless arrangements have been made otherwise. I agree to give at least 24 hours notice of cancellation of appointment, otherwise will be expected to pay for session PLEASE INITIALClient signatureDate Date Format: DD slash MM slash YYYY This iframe contains the logic required to handle Ajax powered Gravity Forms.