Your Journey to Wellness Starts Here

To ensure your treatment is safe, effective, and perfectly tailored to your needs, please take a moment to complete this health intake form. Your comfort and safety are our top priorities. All information shared is strictly confidential and will help our therapists provide the best possible care for you.

About You

Name *

Last Name *

Date of birth *

Email address *

Phone number *

Emergency Contact Name & Phone *

Health History

Are you taking any medication? *

Yes

No

Please list medication name and use below

Are you currently pregnant? *

Yes

No

How far along are you? (In case of Yes)

Please indicate any of the following that apply to you:

Cancer

Headaches/Migraines

Arthritis

Diabetes

Joint Replacement(s)

High/Low Blood Pressure

Neuropathy

Fibromyalgia

Stroke

Heart Attack

Kidney Dysfunction

Blood Clots

Numbness

Sprains or Strains

Explain any conditions you have marked above (If Marked)

Do you have any allergies or sensitivities *

Yes

No

Please explain your allergies and/or sensitivities (In case of Yes)

Treatment Preferences

Have you had a professional massage before?

Yes

No

What pressure do you prefer?

Light

Medium

Deep

Are there any areas you do not want massaged? *

Yes

No

Please identify which areas you do not want massaged

What are your goals for this treatment session?

By signing below, you 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. *

Signature date *

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