ANGELEE OH MASSAGE

Intake Form

Client Information

First name

Last name

Email

Birthday

Month

Day

Year

Address

Phone

Health Information

What brings you in today?

Please list three areas of the body where you are experiencing pain or discomfort. These areas are where we will focus our session.

Are there any particular modalities/ treatments that you would like to be incorporated into the session? If so, please list.

Are you taking any medications?

yes

no

If yes, please list:

Any allergies? (oils, lotions, nuts, fruits, skin, etc)

Yes

No

If yes, please list:

Are you Pregnant?

Yes

No

If yes, how many months?

Are you currently under medical supervision or receiving other medical interventions?

Yes

No

If yes, please describe:

Areas of swelling

Yes

No

If yes, where?

Autoimmune disorder

Yes

No

Back/neck problems

Yes

No

Blood Clots

Yes

No

Bleeding disorders

Yes

No

Bruise Easily

Yes

No

Bursitis

Yes

No

If yes, where?

Cancer

Yes

No

Contagious Condition

Yes

No

Decreased Sensation

Yes

No

If yes, Where?

Diabetes

Yes

No

Fibromyalgia

Yes

No

Headaches

Yes

No

Heart Condition

Yes

No

Hypertension

Yes

No

Kidney Disease

Yes

No

Multiple Sclerosis

Yes

No

Neurological Condition

Yes

No

Neuropathy

Yes

No

If yes, where?

Osteoarthritis

Yes

No

Osteoporosis

Yes

No

Phlebitis

Yes

No

Sciatica

Yes

No

Seizures

Yes

No

Stroke

Yes

No

TMJ Disorder

Yes

No

Is one side more symptomatic than the other? If so which one?

Tendinitis

Yes

No

If yes, where?

Varicose Veins

Yes

No

Vertigo / dizziness

Yes

No

Areas of broken skin? (rash, wounds)

Yes

No

If yes, where?

History of joint replacement surgery?

Yes

No

If yes, which joint(s) and when (Month/Year)?

Recent injuries or medical procedures in the last 2 years?

Please describe any other injuries or health conditions (Month/Year):

Massage Information

Have you had a professional massage before?

Yes

No

How recently?

What would make this appointment a success?

By signing below, I acknowledge that I am aware of the benifits and risks of massage therapy and that I have completed this form to the best of my knowledge. I also agree to inform my massage therapist of any health or medical changes

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Date

Month

Day

Year