Intake Form

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FAQ

Home
Services
- Facials
- Massage
Contact Us
Blog
Our Locations
- Bushwick Brooklyn Sports Massage
- Downtown Brooklyn Sports Massage
FAQ

BOOK NOW

Name

Phone (Day)

Phone (Night)

Email

Date of Birth

Address

City/State/Zip

Occupation

Employer

Primary Physician

Emergency Contact Information

Name

Relationship

Phone

Are you taking any medication

Yes No

If yes, please list name and use?

Are you currently pregnant?

Yes No

If yes, how far along?

Any high risk factors?

Do you suffer from chronicpain?

Yes No

If yes, please explain

What makes it better?

What makes it worse?

Have you had any orthopedic injuries?

Yes No

If yes, please list:

Please indicate any of the following that apply to you.

Cancer Fibromyalgia Headaches/Migraines Stroke Arthritis Heart Attack Diabetes Kidney Dysfunction Joint Replacement(s) Blood Clots High/Low Blood Pressure Numbness Neuropathy Sprains or Strains

Explain any conditions you have marked above:

What type of massage are you seeking?

Relaxation Therapeutic/Deep Tissue Other

If other, please specify:

Have you had a professional massage before?

Yes No

What pressure do you prefer?

Light Medium Deep

Do you have any allergies or sensitivities?

Yes No

Please explain:

Are there any areas (feet, face, abdomen, etc.) you do not want massaged?

Yes No

Please explain:

What are your goals for this treatment session?

Please indicate the areas on your body that are causing you discomfort:

I hereby confirm that I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time.