Massage Intake form

If yes how recently?

What type of massage/body work do you prefer?

What are your goals/expected outcomes for receiving massage/bodywork?

In the last week how do you feel today?

List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):

Do these symptoms interfere with your activities of daily living (e.g., sleep, exercise, work, childcare)? Yes or No

List the medications you currently take:

Have you had any injuries or surgeries in the past that may influence today’s treatment?

Muscle or joint pain? Please specify whether the condition is past or current and include a brief explanation. If not applicable, leave blank.

Muscle or Joint Stiffness? Please specify whether the condition is past or current and include a brief explanation. If not applicable, leave blank.

Numbness or tingling? Please specify whether the condition is past or current and include a brief explanation. If not applicable, leave blank.

Swelling? Please specify whether the condition is past or current and include a brief explanation. If not applicable, leave blank.

Bruise Easily? Please indicate current or past and explain if none leave blank

Sensitive to touch/preasure? Please specify whether the condition is past or current and include a brief explanation. If not applicable, leave blank.

High/Low Blood Pressure? Please specify whether the condition is past or current and include a brief explanation. If not applicable, leave blank.

Stroke, heart Attack? Please specify whether the condition is past or current and include a brief explanation. If not applicable, leave blank.

Varicose Veins? Please specify whether the condition is past or current and include a brief explanation. If not applicable, leave blank.

Shortness of Breath, Asthma? Please specify whether the condition is past or current and include a brief explanation. If not applicable, leave blank.

Cancer? Please specify whether the condition is past or current and include a brief explanation. If not applicable, leave blank.

Neurological (e.g. MS, Parkinson’s, chronic pain)? Please specify whether the condition is past or current and include a brief explanation. If not applicable, leave blank.

Epilepsy, Seizures? Please specify whether the condition is past or current and include a brief explanation. If not applicable, leave blank.

Headache, migraine? Please specify whether the condition is past or current and include a brief explanation. If not applicable, leave blank.

Dizziness, ringing in the ears? Please specify whether the condition is past or current and include a brief explanation. If not applicable, leave blank.

Digestive conditions (e.g. Crohn's, IBS)? Please specify whether the condition is past or current and include a brief explanation. If not applicable, leave blank.

Gas, bloating, constipation? Please specify whether the condition is past or current and include a brief explanation. If not applicable, leave blank.

Kidney disease, infection? Please specify whether the condition is past or current and include a brief explanation. If not applicable, leave blank.

Arthritis (rheumatoid, osteoarthritis)? Please specify whether the condition is past or current and include a brief explanation. If not applicable, leave blank.Joint Pain? Please indicate current or past and explain if none leave blank

Osteoporopsis, degenerative spine/disk? Please specify whether the condition is past or current and include a brief explanation. If not applicable, leave blank.

Scoliosis? Please specify whether the condition is past or current and include a brief explanation. If not applicable, leave blank.

Broken Bones? Please specify whether the condition is past or current and include a brief explanation. If not applicable, leave blank.

Allergies? Please specify whether the condition is past or current and include a brief explanation. If not applicable, leave blank.

Diabetes? Please specify whether the condition is past or current and include a brief explanation. If not applicable, leave blank.

Endocrine/ Thyroid Conditions? Please specify whether the condition is past or current and include a brief explanation. If not applicable, leave blank.

Depression, anxiety? Please specify whether the condition is past or current and include a brief explanation. If not applicable, leave blank.

Memory Loss, confusion, easily overwhelmed? Please specify whether the condition is past or current and include a brief explanation. If not applicable, leave blank.

Health History

Please indicate whether the condition is past or current. If no condition is present, leave this field blank.

More Than a Gym, It's a Community