Massage Therapy Intake Form
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Personal Info
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Contact Info
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Virgin Islands, U.S.
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Province / State
Postal / Zip Code
Emergency Contact
Emergency Contact
Emergency Phone
Relationship
Doctor
Doctor's Name
Doctor's Phone
Doctor's Address
Conditions
Energy Level
Fatigue
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High
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Low
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Agitated
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Health Questions
Congenital Heart Defect
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Depression
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Diabetes
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Epilepsy
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Gastrointestinal
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Hearing Impairment
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Heart Attack
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Heart Condition
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High blood pressure
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HIV/Aids
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Low blood pressure
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Migraines/Headaches
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Mood Disorder
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Pacemaker
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Past Heart Surgery
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Stroke
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aricose veins
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Vertigo
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Asthma
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Blood thinner medication
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Cancer
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Cardiovascular
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Concussion
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Treatment Goals
Improve Well Being
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Stress Relief
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Improve Lifestyle
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Pain Relief
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Support in Healing/Recovery
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Improve Symptoms
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Rehabilitation
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Health Advice for Healing
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Other
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Emotion / Memory
Anxiety Disorder
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Stress
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Female Health
Menopause
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Osteoporosis
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Currently Pregnant
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Infectious
Presence of any infectious condition?
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Oncology
Cancer Type
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Location
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Date of Diagnosis
Area of Complaint
Neck
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Low Back
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Left Leg
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Right Hip
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Upper Back
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Left Shoulder
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Right Leg
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Sacrum
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Mid Back
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Right Shoulder
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Left Hip
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Brain Disorders
Bipolar Disorder
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PTSD
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Anxiety
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Autism
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Acute Stress Disorder
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Depression
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ADHD
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Headaches
Headaches
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Sinus
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Tension
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Neurological
Fibromyalgia
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Stroke
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Brain Injury
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Immune
Cancer
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Rheumatoid Arthritis
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Lupus
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Non-Hodgkin Lymphoma
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Gastrointestinal
Digestive Conditions
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Celiac Disease
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Irritable Bowel Syndrome
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Other Gastrointestinal
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Hiatal Hernia
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Constipation
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Stomach Disorder
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Crohn's Disease
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Diarrhea
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Acid Reflux
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Musculoskeletal
Whiplash
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Joint Stiffness / Swelling
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Jaw Pain (TMJD)
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Joint Injury
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Other Musculoskeletal
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Cardiovascular
Blood Pressure
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High Blood Pressure
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Heart Condition
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Heart Disease
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Low Blood Pressure
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Respiratory
Asthma
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Bronchitis
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Emphysema
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Other Respiratory
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Kidney
Bladder Disorder
Endocrine
Diabetes
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Acute Pancreatitis
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Adrenal Fatigue
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Skin
Acne
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Oily Skin
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Eczema
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Sensitive Skin
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Dry Skin
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Miscellaneous
ADHD
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Autism
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Loss of Balance
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Vision Loss
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Insomnia
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Other Diagnosed Diseases
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Massage Goals
Address Health Issues
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Improve Symptoms
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Pain Relief
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Alternative Therapy
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Increase Well-Being
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Stress Relief
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Balance
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Injury Rehabilitation
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Other
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Accident Info
Date of Injury
Which best describes what you are experiencing?
Pain
1
2
3
4
5
Mild
Severe
Tension
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Imbalance
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Allergy
Sensitive to scents/essential oils
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Other Allergies
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Emotion Mood
Mental Abuse History
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Stress Response and Coping Strategies
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Anxiety
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Depression
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PTSD
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Grief
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Sadness
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Anger
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Confusion
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Physical Abuse History
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Fear
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Negative Self-Talk
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Other Emotions
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Overall mood and energy level
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Despair
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Rate the stress in your life (1-10)
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