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"Wonderful, relaxing... won't go anywhere else now, Donna did a great job. "
-Anonymous

General Intake Form

Name

Date

Street Address

Address Line 2

City

State/Province/Region

Postal Zip Code

Country/Region

Email

(Email addresses will not be used for any other purpose or be distributed or sold to any third party.)

Date of Birth

Home Phone

Work Phone

Cell Phone

Who may we thank for referring you?

Are you under a physician's care?
YesNo

If yes,please explain:

Are you taking any medications?
YesNo

If yes,list medications and/or conditions associated with medications:

Do you have any allergies? If so, please list:

Have you had any surgeries in the last month?
YesNo

If yes, please explain:

Have you ever received a professional massage?
YesNo

Are you pregnant?
YesNo

Please check all those that apply:
Muscle Tightness or SorenessTrouble SleepingRestless LegsInflammationAnxietyHeadachesStressRecent InjuryTensionAching LegsContagious DiseaseArthritis

If there are other choices not listed that apply to you and need mentioning, list here:

Is there a specific body area on which you would like the therapist to concentrate?:
(example: shoulders, neck, low back, etc.)

What results would you like to achieve?

Have you receieved any other treatment for your condition?
MedicationSurgeryPhysical TherapyChiropractic CareOther

If there are other choices not listed that apply to you and need mentioning, list here:

I understand that this is a professional massage/reflexology session and is in
no way, sexual in nature. If the practitioner feels that any inappropriate gestures are made by the client, he/she reserves the right to end the session immediately, with payment due in full.

I understand that Massage and Reflexology are compliments to healthcare and not a substitute for medical supervision of any condition. If I have any medical condition that requires a physician’s care, I have consulted him/her regarding receiving a Massage/Reflexology treatment, and either have their consent, or have taken responsibility for the session upon myself. I certify that the above information is correct to the best of my knowledge. I will not hold my massage therapist or any members of his/her staff responsible for any errors or omissions that I may have made in the completion of this form. I have disclosed all medical conditions that I am aware of and will inform my massage therapist of any changes in my health status.

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