Massage Therapy Intake Form
Personal Information
First / Last name
Email address
Phone number
Birthday
Date
MM
/
DD
/
YYYY
How did you find out about me?
Clear choice
Brevard's Spiritual Connection
Chamber of Commerce - Brevard County
EverythingBrevard.com
Historic Cocoa Village Mainstreet/Website
Referral from Friend
Referral from Medical Office or Practitioner
Google Search
Health Fair
Orlando Spiritual Consciousness
Natural Awakenins
Universal Energy Massage FB Page
Health History
Are you pregnant or breastfeeding?
Yes
No
Do you have any metal implants?
Yes
No
Please list any serious injuries
Please list all surgeries
Please list all allergies (including aromatherapy, food, etc)
Are you allergic to coconut or coconut oil?
Yes
No
Please list any skin problems
Please list all current medications.
Please check any conditions, past or current, which apply to you:
Arthritis
Joint Replacement
Cancer/ Tumor
Migraines
Contagious Disease
Muscular Injuries
Diabetes
Neurological Problems
Digestive Conditions
Open Cuts/ Sores
Disc Herniation
Osteoporosis
Fibromyalgia
Skeletal Injury
Headaches
Stroke
Heart Disease
Swelling/ Clotting Problems
High/Low BP
Varicose Veins
If Other, please list here:
Please choose any chronic, long term conditions you may have:
Select all
Clear choices
Achiness in muscles
Diagnosed Frozen Shoulder
Headaches or Migrains
Hip Pain
Shoulder Tension
Insomnia
Limited Range of Motion in neck
Sore muscles
Tingling down the arm, legs and/or in fingers
Other
If Other, please lsit here:
Is there any traumatic event or experience that may affect your massage that you would like your therapist to know about?
Yes
No
If Yes, please explain.
Have you had....
A car accident
Multiple car accidents
Fall with injury
Broken bones in hand
Broken bones in arm
Broken bones in leg
Fractured hip
Sprained wrist(s)
Sprained ankle(s)
Knee injury
Other
If Other, please list here:
When was your last massage?
Is massage....
Part of your lifestyle
A luxury
For healing from injury
Other
If Other, please lsit here:
What are your focus areas and preferences for massage?
Ams
Back
Head
Hips
Legs
Neck
Shoulders
Sinuses
TMJ/Jaw
Full Body
Consent
By signing this consent form, I understand that Eileen Bild does not diagnose illness, disease or any other medical disorder. Eileen Bild does not provide medical treatment or pharmaceuticals. I understand that any services provided are not a substitution for medical treatment and that I should see a physician for any physical ailment that I might have. I understand that the massage I receive is provided for the purpose of relaxation and/or relief of muscular tension. If I experience any discomfort during the session, I will immediately inform the therapist so that the pressure and strokes may be adjusted. Because practitioners must be aware of any existing physical conditions, I have stated all my known medical conditions. Therefore, I assume all risk for my health and hold harmless Eileen Bild and any associated business entities, practitioners, Amenities or persons involved in services performed. I also understand that the License Massage Therapist reserves the right to refuse or terminate the massage session to anyone whom she considers to have a condition for which massage is contraindicated.
Today's Date
MM
/
DD
/
YYYY
Signature
Clear
Verification
SUBMIT FORM
Please wait...
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20