Health Intake Form

For your convenience, you may fill out the health form below before your appointment.

Client Information
Name *
Name
Address *
Address
Phone *
Phone
Date *
Date
Date of Birth *
Date of Birth
Massage History/ Session Information
If yes, how often have you received massages?
If yes, please explain.
If yes, explain
Do you wear any of the following? *
If yes, please describe.
If yes, please describe.
If so, how has this affected your health? Ie. irritability, insomnia, etc.
If yes, please describe.
If yes, please describe.
Medical History
In order to plan a massage session that is safe and effective, I need some general information about your medical history.
Please mark any of the following that you now have or have had.
Type your name below to sign the agreement.