Massage Intake Form
confidential massage intake form
If you'd like to save a little time before your first appointment, please complete the following form. Please note that all of the information you provide is confidential, and will only be reviewed by your massage therapist.
Date of Birth
1. How often do you get a massage?
Never; this is my first time
A few times per year
2. If you have difficulty laying in any of the following positions, please indicate:
On your back
On your front
On your right side
On your left side
No problems with any of the above
3. Any allergies to oils, lotions or ointments?
4. Do you have sensitive skin?
5. Do you sit for long periods of time? If yes, please describe.
6. Do you perform repetitive movements in your work, sports or hobby? If yes, please describe.
7. Are you under a lot of stress due to work, family or other areas of your life?
8. Are you experiencing muscle tension, anxiety, insomnia or irritability? If so, please describe.
9. Is there a particular area of the body where you are experiencing tension, stiffness, pain or other discomfort? Please describe.
10. Do you have any particular goals in mind for this massage session, or are there areas that you'd like to focus on? Please describe.
11. Are you currently under medical supervision? If so, please explain.
12. Are you currently taking any medications? If so, please list:
13. Please check any conditions that apply:
contagious skin condition
open sores or wounds
recent accident or injury
high or low blood pressure
13. Conditions (cont'd)...
deep vein thrombosis/blood clots
joint disorder/rheumatoid arthritis
carpal tunnel syndrome
14. Please feel free to elaborate on any of the conditions that you have checked above:
15. Is there anything else that you think would be useful for your massage practitioner to know to plan a safe and effective massage session for you?
Thanks for completing this massage intake form. After you click submit you'll be redirected to our online booking platform where you can schedule your appointment. Once you've booked an appointment you'll receive an email confirmation with a request to complete the
for Zenyasa Studio, which you can also complete online to save a little time at the studio.
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Massage Intake Form