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

For Body * Mind * Spirit

New Clients:  You are welcome to fill out the intake form before your first session and bring it with you.   Just select the form below, click Ctrll+P to print.  Or, we will take a few extra minutes to complete the form at your session.   Thanks!

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 tension, muscle spasms, or poor circulation.  The massage therapist cannot diagnose medical issues/diseases/disorders or perform spinal manipulations/chiropractic.

 

 

_________________________________                                   ______________________________

Signature                                                                                               Date