Want Us To Contact You? Back Continue Submit We will be in touch shortly. Pro10 Massage Intake Form Leave this field blank Massage Intake Form Personal Information Name Phone (Day) Phone (Evening) Address City/State/Zip DOB Occupation Employer Email Primary Physician Emergency Contact Relationship Phone How did you hear about us? Medical Information Have you taken any medication? YES NO Are you currently pregnant? YES NO If yes, please list name and use If yes, how far along? Do you suffer from chronic pain? YES NO If yes, please explain What makes it better? What makes it worse? Have you had any orthopedic injuries? YES NO If yes, please list: 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 Disfunction Blood Clots Numbness Sprains or Strains Explain any conditions you have marked above: Massage Information Have you had a professional massage before? YES NO What type of massage are you seeking? Relaxation Therapeutic/Deep Tissue Other Do you have any allergies or sensitivities? YES No If yes, please explain Are there any areas (feet, abdomen, etc) you do not want to have massaged? YES NO If yes, please explain 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 acknowledge and agree to inform my therapist if any of the above information changes at any time. Client Signature Start drawing Clear Done Start over Date Therapist Signature Start drawing Clear Done Start over Date Submit Book A Session
