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Gerellie Massage client intake form

Name

*

Email Address

*

Phone Number

*

Health Information

Any Allergies? (oils, lotions, skin, etc.)

*

Any Allergies? (oils, lotions, skin, etc.)

Yes

No

Areas of broken skin? (e.g. rash, wounds)

*

Areas of broken skin? (e.g. rash, wounds)

Yes

No

If yes, Where?

History of joint replacement surgery?

*

History of joint replacement surgery?

Yes

No

Which joint(s) ?

Recent injuries or medical procedures in the past 2 years?

*

Recent injuries or medical procedures in the past 2 years?

Yes

No

If yes, Please describe:

*

Massage Information

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Please indicate any areas of discomfort (Right Side)

*

Please indicate any areas of discomfort (Right Side)

R 1

R2

R3

R4

R5

R6

R7

R8

R9

R10

R11

R12

R13

R14

Please indicate any areas of discomfort (Left Side)

*

Please indicate any areas of discomfort (Left Side)

L1

L2

L3

L4

L5

L6

L7

L8

L9

L10

L11

L12

L13

L14

What type of massage would like? (You can choose more than one.)

*

What type of massage would like? (You can choose more than one.)

How much pressure do you prefer?

*

How much pressure do you prefer?

A

Light

B

Medium

C

Firm

By signing below, I acknowledge that I am aware of the benefits and risks of massage therapy and that I have completed this form to the best of my knowledge. I also agree to inform my massage therapist of any health or medical changes.

Client Signature

*

Signature