ABSOLUTE MASSAGE - LOS ANGELES
THE ABSOLUTE BEST IN INTEGRATED MASSAGE THERAPY TECHNIQUES  

For Body * Mind * Spirit

NEW CLIENTS:  Please call 310.429.2488 or email massagebystella@gmail.com before you book your first appointment so we can discuss your specific goals with respect to massage therapy.  Once we've set your first appointment, you can fill out the intake form below and bring it with you.   Just select the form below, click Ctrl+P to print.  Or, we will take a few extra minutes to complete the form before your session.   Thanks and we look forward to meeting you!

EXISTING CLIENTS: 
Please feel free to use the "Book Now" button (momentarily under construction) to schedule, or you can still make an appointment the old-fashioned way by either calling or texting at 310.429.2488 or emailing at massagebystella@gmail.com.  Looking forward to seeing you!


ABSOLUTE MASSAGE

CLIENT INTAKE FORM

PERSONAL INFORMATION

 

Name:    _______________________________        Date: ______________________

Address: ______________________________________________________________

City: _________________    State:  ________________   Zip: ___________________

Phone:  _____________________   Email:  __________________________________

DOB:  ______________________

How did you hear about Absolute Massage (referral, Facebook, other ads):

______________________________________________________________________

 

HISTORY

 

Exercise Frequency: ____________________  Exercise Type(s) __________________

Do you smoke: ______________  Smoked and quit? _________________

How much water do you drink daily? _____________________________

Prescription drugs: ____________________________________________

Previous complaints, surgeries, medications?  _________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

Current major complaint: _________________________________________________

______________________________________________________________________

Have you received massage therapy before? __________________________________

Goals for massage therapy:   □ Relaxation    □ Injury Rehabilitation     □ Maintenance

Preferred type of touch:   □ Light     □ Deep

 

CURRENT CONDITIONS

 

□ Sunburn                           □ Cuts/Burns/Bruises                      □ Inflammation                           □ Skin Rash

□ Headache                        □ Severe Pain                                   □ Poison Ivy                                 □ Cold or Flu

□ Asthma                            □ Arteriosclerosis                             □ Pregnancy                                 □ Arthritis

□ Diabetes                           □ Varicose Veins                              □ Hernia                                        □ Stomach Ulcer

□ Epilepsy                           □ Dizziness                                        □ Cancer                                       □ Pins/Pacemaker

□ Depression                       □ High Blood Pressure                    □ Low Blood Pressure                 □ Contact Lenses

□ Heart Disease                  □ Hemophilia                                   □ Musculoskeletal Issues           □ Fibromyalgia

□ Other (please describe)

 

 

 

I understand that massage is designed for the purpose of relaxation and relief from issues such as tension, muscle spasms, or poor circulation.  The massage therapist cannot diagnose medical issues/diseases/disorders or perform chiropractic work.

 

 

_________________________________                                   ______________________________

Signature                                                                                               Date