M, T 9am to 5pm | W, Th 1pm to 6pm | F 9am to 3pm

    Massage & Bodywork Intake Form

    *All information will be kept strictly confidential. Your responses will allow us to get a more complete picture of your health, uncover contributing factors to your chief complaint(s) and advise you in your health goals. Thank you for investing in your health. We look forward to supporting you!


    Please mark all conditions, past and present, even if they are only occasional:

    Scoliosis/Spinal problemsPastPresent


    Sciatica/Pinched NervePastPresent

    Colds/Flu PastPresent


    Asthma/Bronchitis PastPresent

    Numbness/tingling PastPresent

    Blood clots/HypertensionPastPresent

    Cold hands & feet PastPresent





    Heart disease PastPresent

    Headache/Migraine PastPresent

    Hepatitis/HIV PastPresent

    TMJ/Jaw pain PastPresent

    Lupus/Shingles PastPresent

    Menstrual problemsPastPresent

    Eczema/Psoriasis PastPresent


    Chronic fatigue PastPresent

    Anxiety/Depression PastPresent

    Skin problems/sensitivities (please list below) PastPresent

    Please read the following:

    I have completed this form to the best of my ability and will inform the massage therapist of any change in my physical health.
    I understand that a massage therapist cannot diagnose illness, disease or any other mental, physical or emotional disorder, nor perform any spinal manipulations. I am responsible for consulting a qualified physician for any physical ailments that I have.
    I understand that massage therapy is a therapeutic health-aid and is non-sexual.
    I understand that if the massage therapist starts a session late, she will make it up to me at the end of my session if possible, or will reduce my fee accordingly. I understand that if I arrive late, my session will end at the originally scheduled time so the client following me is not penalized.
    I agree to give 24-hour notice for a scheduled session that I cannot keep. I am aware that I may be charged the full fee for any missed sessions or for sessions that I do not give 24-hour notice to cancel or reschedule.