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MASSAGE INTAKE FORM

*Disclaimer: Thank you for your interest in being a client of Jonathan's Wellness Journey! Information collected about new clients is confidential and will be treated accordingly.

CLIENT INFORMATION

First name

Last name

Multi-line address

Country/Region

Address

City

Zip / Postal code

Email

Phone

Birthday

Month

Day

Year

Emergency Contact

Emergency Contact Phone Number

Occupation

How did you hear about us?

Referred by:

HEALTH INFORMATION

Are you taking any medications?

Yes

No

If yes, please list:

Any allergies? (oils, lotions, nuts, fruit, 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 receiving 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

Please describe:

Please describe any other injuries or health conditions:

MASSAGE INFORMATION

Have you had a professional massage before?

Yes

No

If yes, how recently?

What are your goals for the massage?

How much pressure do you prefer?

Light

Medium

Firm

On a scale of 1-10, how would you rate your pain?

Please list all of your massage preferences (e.g. glute work or not, areas of the body to avoid or to focus on more, etc.)

By signing below, I acknowledge that I am aware of the benefits 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. I also acknowledge the inherent risks and voluntarily assume full responsibility for any injury, damage, or loss that may result from my participation. I hereby waive and release the business, its owners, and its staff from any and all liability, past, present, and future, relating to the services provided.

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Date

Month

Day

Year