Massage Intake Form

Your Name
Have you ever had a professional massage?
Are you pregnant?
If yes, how far along are you?
Are you sensitive to touch/pressure in any areas?
If yes, please explain.
Are you allergic or sensitive to any oils (essential oils, nut oils, scents)?
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.
On a scale from 1-5, 5=highest, rate your levels of Pain.
How did your symptoms begin and when did they start?
What have you done for relief?
Is this condition getting better/worse?
Please check all that apply
If other, please explain

Arch Wellness

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