Client Intake Form - State of Being Massage Therapy

Please fill out the following information and submit below prior to your first session.

Today's Date

Full Name

E-mail

Address

Phone Number

Date of Birth

Occupation

Emergency Contact & Phone Number

Are you under a doctor's care?

Yes
No

Medications

Are you allergic to any oils, lotions, scents or foods?

Yes
No

If yes, please describe.

Are you pregnant?

Yes
No
N/A

If yes, how far along is your pregnancy?

Do you bruise easily?

Yes
No
Uncertain

When was your last massage?

What is the purpose of this massage, or are there any techniques anticipated? (Relaxation, Sore Muscles, etc.?)

Depth of pressure preferred:

Deep
Medium
Light

Is there any area you wish to be avoided? Hair? Any cuts/bruises? Ticklish?

If you feel pain or discomfort during the massage, please immediately inform the therapist so that pressure and/or strokes may be adjusted to your comfort level. Please provide any additional information that you wish the therapist to know.

I understand that the massage services I receive from Heidi Suprun, LMT are designed to be a health aid and are in no way to take the place of a doctor's care when such care is indicated. I also understand that the information exchanged during massage sessions is educational in nature and is intended to help me become familiar and conscious of my own health status and is to be used at my own discretion. Please type your name below to confirm your understanding.