Massage Therapy Intake Form
First / Last name
Phone number and Email address
Emergency Contact Name & Phone Number
List all medications and any allergies
What is your focus area(s)?
Do you have any of the following health history?
Check all that apply:
asthma
allergies
sensitive skin
eczema
bruise easily
varicose veins
diabetes
dizziness
headache/migraines
high blood pressure
heart disease
pacemaker
epilepsy
arthritis
carpal tunnel
scoliosis
plantar fasicitis
bulging disc
fibromyalgia
multiple sclerosis
Other:
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Date
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Verification
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