intake form – heavenlyhealingtouch.in

Please fill out this intake form before your first session with Heavenly Healing Touch Therapy.

Massage Intake Form

Disclaimer: Thank you for your interest in being a client of . Information collected about new clients is confidential and will be treated accordingly.

Name

Email

Street Address

City

State

ZIP

Phone (cell/day)

DOB

AGE

Emergency Contact

Phone

Occupation

Referred by

HEALTH INFORMATION

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:

Due date

Are you currently under medical supervision or other medical interventions?

Yes No

If yes, please describe

Areas of broken skin? (e.g., rash, wounds)

Yes No

If yes, where?

History of joint replacement surgery?

Yes No

If yes, which joint(s)?

Recent injuries or medical procedures in the past 2 years?

Yes No

If yes, please describe

Please describe any other injuries or health conditions:

MASSAGE INFORMATION

Have you had a professional massage before?

Yes No

How recently?

Reason for seeking massage?

Relaxation Specific problem

How much pressure do you prefer?

Light Medium Firm

Please list and describe any areas of discomfort

Are you comfortable with having therapeutic massage on the following areas?

FACE

Yes No

PECTORAL MUSCLES

Yes No

ABDOMEN

Yes No

GLUTEAL REGION

Yes No

FEET

Yes No

Scalp

Yes No

Client Signature

date

Print Name

I confirm that all information provided is accurate.

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Massage Intake Form

Are you comfortable with having therapeutic massage on the following areas?

Contacts