Massage Intake Form Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Date of birth * MM DD YYYY Gender She/Her He/Him They/Them Emergency Contact How did you hear about BodyDivine? Have you received therapeutic massage therapy, bodywork, or Reiki before? Yes No Are you on any medications? Yes No If, yes, please list medications. Do you exercise? Yes No How many time per week? How many hours? What exercise/activity do you do? Please select any condition you have Cancer Headaches/Migraines Fibromyalgia Arthritis Kidney Dysfunction Stroke Diabetes Recent Cold/Flu Sprain or Strain Alcohol within 24 hours Nimbness Hart Attack Phlebitis Bruises High Blood Pressure Varicose veins Acute pain Chronic Pain Recent surgery Open wounds Osteoporosis Neuropathy Blood clot Fever within 24 hours Wear contacts Other condition Are you pregnant? Yes No If so specify how many weeks along are you pregnant and due date? Any high risk factors? Any allergies or sensitivities? Yes No If yes, please explain. What areas would you like to focus on today? What type of massage or therapy are you seeking today? Swedish/Relaxation Therapeutic Myofascial Release Lymphatic Cranio Sacral Reiki What pressure do you prefer? Light Medium Deep Are there any areas you would NOT like massaged? Yes No If yes, please explain What are your goals for this treatment session? I agree that the above information is accurate and to the best of my knowledge and give massage therapist, Anita B. Sykes, owner of Body Divine permission to be massaged today. I agree to inform the therapist if I experience any pain or discomfort during the session. I understand that massage therapy is for the purpose of stress reduction, relief from muscular tension or spasm, or for increasing circulation. I understand that the massage therapist does not diagnose illness, disease or any other physical or mental disorder. The massage therapist does not prescribe medical treatment nor perform spinal manipulations. I will inform the therapist of my current condition at the time of each visit. I agree Thank you!
