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Massage Intake Form

The following information will be used to help plan safe and effective massage sessions. Please answer the questions to the best of your knowledge.

1. Have you had a professional massage before?
2. Do you have any difficulty lying on your front, back, or side?
3. Do you have any allergies to oils, lotions, or ointments?
4. Do you have sensitive skin?
5. Are you wearing any of the following? Check all that apply.
6. Do you sit for long hours at a workstation, computer, or driving?
7. Do you perform any repetitive movement in your work, sports, or hobby?
8. Do you experience stress in your work, family, or other aspect of your life?
If yes, how do you think it has affected your health? Check all that apply.
9. Is there a particular area of the body where you are experiencing tension, stiffness, pain or other discomfort?
10. Do you have any particular goals in mind for this massage session?

Medical History
In order to plan a massage session that is safe and effective, I need some general information about your medical history.

11. Are you currently under medical supervision?
12. Do you see a chiropractor?
13. Are you currently taking any medication?
14. Please check any condition listed below that applies to you:
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