NEW CLIENT INTAKE FORM – ZEL'S Massage & Fitness Zone

Massage Intake Form

Name

Email

Phone Number

Address

City/State/Zip

Date of Birth

Emergency contact

Relationship

Are you taking any medications?

Yes No

If yes, please list:

Are you currently pregnant?

Yes No

If yes, how far along?

Any high risk factors?

Do you suffer from chronic pain?

Yes No

If yes, please explain: What makes it better and what makes it worse?

Do you currently have any injuries?

Yes No

If yes, please explain

Have you had a professional massage before?

Yes No

Other

Do you have any allergies or sensitivities?

Yes No

If yes, Please explain

Are there any areas you don't want massaged?

Yes No

Please circle any areas of discomfort or tenderness and Upload:

Please explain any conditions or areas of discomfort you have marked above:

I have completed this form to the best of my ability, and I agree to inform my therapist if any of the above information changes: