Intake Form | Indiana, PA | Indiana Sports Massage

Readers Choice Award

HOME
ABOUT
CORPORATE CHAIR MASSAGE
MASSAGE
REVIEWS
CONTACT
INTAKE FORM

INTAKE FORM

INTAKE FORM

Name*

Phone*

Address

City

State

Zip

DOB

Occupation

Employer

Email*

Primary Physician

Emergency Contact

Relationship

Phone

How did you hear about us?

Medical Information

Medical Information

Are you taking any medications?

Yes

No

If yes, please list name and use:

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?

What makes it worse?

Have you had any orthopedic injuries?

Yes

No

If yes, please list:

Please indicate any of the following that apply to you.

Cancer

Headaches/Migraines

Arthritis

Diabetes

Joint Replacement(s)

High/Low Blood Pressure

Neuropathy

Fibromyalgia

Stroke

Heart Attack

Kidney Dysfunction

Blood Clots

Numbness

Sprains or Strains

Explain any conditions you have marked above:

Massage Information

Massage Information

Have you had a professional massage before?

Yes

No

What type of massage are you seeking?

Relaxation

Therapeutic/Deep Tissue

Other

What pressure do you prefer?

Light

Medium

Deep

Do you have any allergies or sensitivities?

Yes

No

Please explain

Are there any areas (feet, face, abdomen, etc.) you do not want massaged?

Yes

No

Please explain

What are your goals for this treatment session?

Please specify any areas of discomfort

By signing below, you agree to the following. I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time.

By signing below, you agree to the following. I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time.

Client's Signature

Date

Therapist Signature

Date

Thank you for contacting us.
We will get back to you as soon as possible.

Oops, there was an error sending your message.
Please try again later.

HOME
ABOUT
CORPORATE CHAIR MASSAGE
MASSAGE
REVIEWS
CONTACT
INTAKE FORM

CONTACT INFORMATION

Phone: (724) 541-5612

Email: indianasportsmassage@gmail.com

Address: 665 Philadelphia Street,

Suite #000, Indiana, PA 15701

BUSINESS HOURS

Mon - Sat: 10:00 am - 6:00 pm
Sunday: Closed

If these hours do not work, please call or text (724) 541-5612, and we'll fit you in!

PAYMENT METHODS

Visa

Mastercard

American Express

Discover

Cash

Check

© 2024

All Rights Reserved | Indiana Sports Massage

Share by: