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Massage Intake Form
Your Name
Have you ever had a professional massage?
Yes
No
Are you pregnant?
Yes
No
Does not apply
If yes, how far along are you?
Are you sensitive to touch/pressure in any areas?
Yes
No
If yes, please explain.
Are you allergic or sensitive to any oils (essential oils, nut oils, scents)?
Yes
No
If yes, please list:
List of current medications and reason:
List of surgeries (type and date):
On a scale from 1-5, 5=highest, rate your levels of Stress.
1
2
3
4
5
On a scale from 1-5, 5=highest, rate your levels of Pain.
1
2
3
4
5
How did your symptoms begin and when did they start?
What have you done for relief?
Is this condition getting better/worse?
Better
Worse
Does not apply
Please check all that apply
Skin condition-rash,warts, hives, skin cancer
Lymphatic condition-swollen gland, nasal congestion, lymph edema
Joint problems/stiffness-arthritis, sacroiliac problems, TMJ
Bone Condition-osteoporosis, fracture
Headaches
Recent injury or accident-whiplash, sprain, bruise
Circulatory Condition- high blood pressure, varicose veins, blood clots
Numbness/Tingling Sciatica
Tendonitis, Bursitis
Diabetes
Other/None of the above
If other, please explain
Submit Form
Arch Wellness
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Home
About
Blog
Book Your Appointment
Packages
Office Chair Massage
Forms
New Client Intake
Facial/Skincare Intake Form
Massage Intake Form
Sugaring/Waxing Form
Contact
Appointment Policy
Products
My account
Account
Checkout
Cart
0 items
$0.00