Massage Intake Form

Massage Health History Form

Please fill out the following health history form, as thoroughly as possible. The answers to these questions will help us to help you better.

Thank you! Emily Boudwin, Restorative Health and Wellness

First Name

Last Name

Todays Date

Phone/Mobile

Address Line 1

Address Line 2

City

State

Zip Code

Occupation

Employer

Primary Physician

Emergency Contact

Emergency Contact Phone Number

Emergency Contact Relationship

How did you hear about us?

If you take medications, please list ALL and reasons for taking them.

Are you currently pregnant?

Yes

If you are pregnant, when is your due date?

Any high risk factors with your pregnancy? Please explain, if yes.

Do you suffer from chronic pain?

Chronic Pain: please describe your chronic pain

Chronic Pain/discomfort level: 0=no pain 10=excruiating

What makes your chronic pain better?

What makes your chronic pain worse?

Please explain any conditions that you have marked above. If you selected other, please explain.

What position do you typically sleep in at night?

Do you have any allergies or sensitivities? If yes please explain:

Have you had a professional massage before?

What level of pressure do you prefer?

What are your goals for this massage treatment session?

I have read and agree to the Terms and Conditions and Privacy Policy

Voluntary Informed Consent for massage therapy

Emily Boudwin provides neuromuscular massage therapy and restorative exercise-personal training. She will focus on your specific areas of concern, specific to the muscular system of the body. She appropriately covers the body, and only has the area that is being worked on uncovered. She avoids working on breast and genital areas.

Massage and/or restorative exercise personal training is not intended or implied to supplement or replace professional medical treatment, advice, and/or diagnosis. Always check with your own physician or medical professional before you receive massage and/or personal training.

I have read and agree to the Voluntary Informed Consent for massage therapy.