Massage Intake Form

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Massage Intake Form

For the following services:

Massage

Hopi Ear Candling & Head Massage

Chakra Healing Therapy

Are you Pregnant?

Yes

No

Medical Information

Are you taking any medications?

Yes

No

Do you suffer from chronic pain?

Yes

No

Please indicate any of the fllowng. that apply to you:

Cancer

Headaches/Migraines

Arthritis

Diabetes

Joint Replacement(s)

High/Low Blood Pressure

Fibromyalgia

Stroke

Heart Attack

Kidney Dysfunction

Blood Clots

Numbness

Neuropathy

Sprains/Strains

Massage Information

Have you had a professional massage before?

Yes

No

What type of massage are you seeking?

Relaxation

Therapeutic/Deep Tissue

What pressure do you prefer?

Light

Medium

Deep

Do you have any allergies/sensitivities?

Yes

No

I agree to the terms & conditions

I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time.

Your Signature