Intake Form | Indiana, PA | Indiana Sports Massage

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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

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ABOUT
CORPORATE CHAIR MASSAGE
MASSAGE
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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!

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