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Massage Intake Form

Step 1 of 3

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Client Info
Client Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Age*
Date of Birth*
MM slash DD slash YYYY
Occupation
Email*
Referred By
Physical Physician
Emergency Contact*
First Last
Contact Phone*

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Medical History
Please take a moment to carefully read the following information and sign where indicated. If you have a specific medical condition or specific symptoms, massage/bodywork may be contraindicated.
Have you ever experienced a professional massage or bodywork session?*
How Recently?*
What are your massage or bodywork goals?*
What kind of pressure do you prefer?*
Do you frequently suffer from stress?*
- Yes
- No
Please Explain as clearly as possible.*
Do you bruise easily?*
- Yes
- No
Please Explain as clearly as possible.*
Any broken bones in the past two years?*
- Yes
- No
Please Explain as clearly as possible.*
Are you pregnant?*
- Yes
- No
Please Explain as clearly as possible.*
Do you experience frequent headaches?*
- Yes
- No
Please Explain as clearly as possible.*
Do you suffer from back pain?*
- Yes
- No
Please Explain as clearly as possible.*
Do you have tension or soreness in a specific area?*
- Yes
- No
Please Explain as clearly as possible.*
Are you wearing contact lenses?*
- Yes
- No
Are you wearing dentures?*
- Yes
- No
Please Explain as clearly as possible.*
Do you have any allergies?*
- Yes
- No
Please Explain as clearly as possible.*
Any injuries in the past two years?*
- Yes
- No
Please Explain as clearly as possible.*
Do you have varicose veins?*
- Yes
- No
Please Explain as clearly as possible.*
Do you have diabetes?*
- Yes
- No
Please Explain as clearly as possible.*
Do you have cardiac or circulatory problems?*
- Yes
- No
Please Explain as clearly as possible.*
Do you have high blood pressure?*
- Yes
- No
Please Explain as clearly as possible.*
Taking high blood pressure medication?*
- Yes
- No
Please Explain as clearly as possible.*
Do you have osteoporosis?*
- Yes
- No
Please Explain as clearly as possible.*
Do you suffer from epilepsy or seizures?*
- Yes
- No
Please Explain as clearly as possible.*
Do you have any contagious diseases?*
- Yes
- No
Please Explain as clearly as possible.*
Do you suffer from joint swelling?*
- Yes
- No
Please Explain as clearly as possible.*
Have numbness or stabbing pain?*
- Yes
- No
Please Explain as clearly as possible.*
Are you sensitive to touch or pressure in any area?*
- Yes
- No
Please Explain as clearly as possible.*
Have you ever had surgery?*
- Yes
- No
Please Explain as clearly as possible.*
Other medical condition, or are you taking any medications I should know about?*
- Yes
- No
Please Explain as clearly as possible.*

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Consent to Treatment of Minor
Because the selected age was below 18, a parent or guardian signature is required. br />
By my signature below, I hereby authorize beyond massage Aspen Staff to administer massage, bodywork, or somatic therapy techniques to my child or dependent as they deem necessary.
Parent/Guardian Name
First Last
Parent/Guardian Signature*

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First Name
Last Name
Email Address

53532

Locations:

Aspen
300 S. Spring St. Suite 203
Aspen, CO 81611

Basalt
214 Midland Ave.
Basalt, CO 81621

Phone:
(970) 274-8717

Office Hours

Mon: 8:30am-6:30 pm
Tue: 8:30am-6:30 pm
Wed: 8:30am-6:30 pm
Thu: 8:30am-6:30 pm
Fri: 8:30am-6:30 pm
Sat: Open Saturday's again in December
Sun: Closed

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