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bodywork and massage intake form

all fields MUST be filled in.

about you

body shape

general health information

are you currently seeing other health care professionals? (check all that apply)
how would you rate your general health?
do you have any previous experience with massage therapy?

reason for visit

how often do you feel pain/discomfort:
pain/discomfort is brought on/made worse by:
pain intensity:
how does the pain/discomfort feel:
pain/discomfort feels better with:

health history

head / neck:
nervous system:
skin / infections:
musculoskeletal system:
other conditions:
muscle / joint pain:
for women:


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