Health Intake Form

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KEL'S MOBILE MASSAGE

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IMPORTANT Please book your appointment before filling out the Health Intake Form.

Basic Information

First Name

Email Address

Emergency Contact Name

Last Name

Phone

Emergency Contact Relationship

Birth Date

Occupation

Emergency Contact Phone

Massage Location

Address 1

Address 2

CIty

State/Province

Zip/Postal Code

Country

Medical Information

Are you taking any medications?

Are you currently pregnant?

Do you suffer from chronic pain?

If yes, please list name and use:

If yes, how far along:

Any high risk factors?

If yes, please explain:

What makes the chronic pain better?

What makes the chronic pain worse?

Have you had any orthopedic injuries?

If yes, please list:

Please indicate any of the following that apply to you:

Cancer

Headaches/Migranes

Arthritis

Diabetes

Joint Replacement

High/Low Blood Pressure

Neurotherapy

Fibromyalgia

Stroke

Heart Attack

Kidney Dysfunction

Blood Clots

Numbness

Sprains or Strains

Recent Surgery

Blood Thinners

Explain any conditions you have marked above:

Are there any other conditions that are not listed above?

Have you had a professional massage before?

Do you have any allergies or sensitivities?

What pressure do you prefer? *

Light

Medium

If yes, please explain:

What are you goals for this treatment session?

Aromatherapy is included in the session free of charge. Which essential oil would you prefer?

Lavender

Eucalyptus

Peppermint

None

By typing your name below, I agree that all the information above is true.

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Thank you!

Kel's Mobile Massage

kelvins.massage@gmail.com

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Health Intake Form

**IMPORTANT** Please book your appointment before filling out the Health Intake Form.

Basic Information

Massage Location

Medical Information

IMPORTANT Please book your appointment before filling out the Health Intake Form.