Medical Massage & Holistic Therapies By Laurée Sine - Licensed Medical Massage Therapist Massage Intake Form, fill in only the first time you make an appointment

First and last name *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Phone *

Email Address *

Occupation

Birthday *

How did you find us

Have you ever had any surgeries, injuries & treatmentsNoYes, please descripe type, location and date:

Are you currently under the care of a doctor or specialist for any condition?NoYes, please descripe type, location and date:

Do you regurlarly use any medications, vitamins or supplements?NoYes, please list:

Are you allergic to anything (e.g., oils, lotions, perfumes, latex?NoYes, please specify:

Do you have a sensitive skin?NoYes

Are you pregnant?

Are there any other important health details we should know?

What is your primary goal or expectation for this massage session?

Have you ever had massages before? If so what type and how often?

Are you currently experiencing pain or discomfort?NoYes, describe location, type of pain and how long you’ve had it:

If you have pain, how often do you experience it?ContinualEvery now and thenOnly when certain movements, namely:

Are there any parts of your body you prefer not to be massaged, or that require special care?

Date