Massage Therapy Intake Form
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Personal Info
First Name
Last Name
Date of Birth (MM/DD/YYYY)
Contact Info
Mobile Phone
Home Phone
Work Phone
Email
Source of Referral
Address
City
Country
Australia
Canada
Ireland
New Zealand
United Kingdom
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua And Barbuda
Argentina
Armenia
Aruba
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia, Plurinational State Of
Bosnia And Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
C?te D'Ivoire
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic Of The
Cook Islands
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island And Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Isle Of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People'S Republic Of
Korea, Republic Of
Kuwait
Kyrgyzstan
Lao People'S Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, The Former Yugoslav Republic Of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States Of
Moldova, Republic Of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Barth?lemy
Saint Helena, Ascension And Tristan Da Cunha
Saint Kitts And Nevis
Saint Lucia
Saint Martin
Saint Pierre And Miquelon
Saint Vincent And The Grenadines
Samoa
San Marino
Sao Tome And Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia And The South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard And Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province Of China
Tajikistan
Tanzania, United Republic Of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks And Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela, Bolivarian Republic Of
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis And Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Province / State
Postal / Zip Code
Emergency Contact
Emergency Contact
Emergency Phone
Relationship
Doctor
Doctor's Name
Doctor's Phone
Doctor's Address
Health History
Area of Complaint
Neck
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Upper Back
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Low Back
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Chest
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Right Shoulder
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Left Shoulder
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Right Arm/Elbow/Wrist/Hand
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Left Arm/Elbow/Wrist/Hand
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Right Hip
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Left Hip
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Right Knee
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Left Knee
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Right Ankle/Foot
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Left Ankle/Foot
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Headaches
Chronic
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Cluster
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Headaches
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Migraine
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Sinus
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Tension
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Neurological
Brain/Spinal Cord Injury
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Epilepsy/Seizure Disorder
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Fibromyalgia
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Loss of Balance
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Multiple Sclerosis
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Stroke
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Vertebral Disc Herniation/Subluxation
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Vertigo/Dizziness
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Musculoskeletal
Arthritis/Osteoarthritis/Psoriatic Arthritis
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Artificial Joints/Pins/Plates/Wires
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Bursitis/Tendonitis
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Compartment Syndrome
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Dislocation/Fracture
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Gout
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Jaw Pain/ TMJD
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Joint Stiffness/Swelling
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Osteomalacia/Osteopenia/Osteoporosis
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Scoliosis
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Strain/Sprain
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Whiplash
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Pain
Burning
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Chronic Pain Disorder
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Deep Aching
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Loss of Sensation/Numbness
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Pins & Needles/Tingling
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Sciatic Pain
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Stabbing/Sharp Shooting
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Skin
Allergic Dermatosis
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Burns - Chemical/Fire/UV
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Herpes
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Infectious Skin Conditions
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Lyme Disease
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Plantar's Warts
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Rash
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Shingles
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Cardiovascular
Chronic Congestive Heart Failure
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Heart Attack
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Heart Disease
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High Blood Pressure
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Low Blood Pressure
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Lymphedema
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Pacemaker
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Poor Circulation
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Phlebitis/Varicose Veins
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Respiratory
Asthma
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Bronchitis
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Chronic Cough
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Emphysema
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Frequent Colds
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Infectious Respiratory Condition
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Respiratory Tract Infection
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Shortness of Breath
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Tuberculosis
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Gastrointestinal
Constipation
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Crohn's Disease
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Diarrhea
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Diverticulitis
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Incontinence
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Indigestion/Heartburn
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Irritable Bowel Syndrome
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Nausea/Vomiting
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Ulcerative Colitis
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Immune
Allergies
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Cancer
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Hepatitis
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HIV/AIDS
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Lupus
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Rheumatoid Arthritis
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Reproductive
Endometriosis
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Given Birth
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Hormone Replacement Therapy
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Menopause
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Pregnant
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Prostate Condition
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Other Conditions
ADHD
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Bipolar Disorder
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Chronic Fatigue
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Depression/Anxiety
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Diabetes
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Gall Stones/Kidney Stones
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Hearing Loss
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PTSD
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Tinnitus
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Other Medical Conditions/Diagnosed Diseases
Family History
Arthritis
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Cancer
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Cardiovascular
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Respiratory
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Injuries
Injury
Add Another Injury
Surgeries
Surgery
Add Another Surgery
Medications
Medication
Add Another Medication
Well Being & Massage Goals
Well Being
Alcohol
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Caffeine
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Exercise
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Smoking
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Supplements
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Water Intake
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Other
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Massage Session Goals
Address Health Issues
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Alternative Therapy
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Balance
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Improve Symptoms
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Increase Well-Being
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Injury Rehabilitation
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Pain Relief
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Stress Relief
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Support in Healing/Recovery
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Other
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Massage Therapy Release Waiver
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