Massage and Bodywork Intake Form Mobile App

Included Fields

Customize to add, remove, or edit any of the fields below.

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  Date

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  Name

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  Address

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  Phone

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  Occupation

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  Date of Birth

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  Emergency Contact Name

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  Emergency Contact Phone

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  Referred By

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  Email

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  Have you ever received a professional massage?

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  Date of last massage

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  What result do you want from your massage sessions?

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  List any exercise activities.

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  Are you currently under the care of a health care practitioner?

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  If yes, specify purpose:

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  List current medications and purpose:

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  (Include year and treatment received)

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  Injuries/accidents/illnesses still affecting you:

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  Surgeries:

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  Please mark any of the following that you now have or have had.

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  Musculoskeletal

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  Bone or joint disease

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  Tendonitis / Bursitis

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  Arthritis / Gout

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  Jaw pain (TMJ)

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  Lupus

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  Spinal Problems

• ...and More!