Intake Form

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Massage by Machelle

Your Wellness Journey Starts Here

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machellewest1629@gmail.com

(636) 579-6908

Please complete the following form or click here to print & complete prior to your visit.

*Any pre-existing medical conditions may require a documented approval from your medical provider prior to your visit.

Thank you for understanding.

Massage By Machelle Intake Form

Today's Date*

First name*

Last name*

Gender*

Male

Female

Address*

Phone (day)*

Phone (evening)

Email*

Occupation*

Employer*

Primary Physician*

Emergency Contact Name*

Phone Number of Emergency Contact*

Relationship to Emergency Contact*

How did you hear about us?*

MEDICAL INFORMATION

Are you taking any medications?*

Yes

No

What is your pain level today on a scale of 1 - 10?*

1 = no pain at all

10 = worst pain of my life

Do you suffer from chronic pain?*

Yes

No

Have you had orthopedic injuries?*

Yes

No

Please list any other conditions we should be aware of.

MASSAGE INFORMATION

Have you had a professional massage before?*

Yes

No

What type of massage are you seeking?*

What pressure do you prefer?*

Light

Medium

Deep

Do you have any allergies or sensitivities?*

Yes

No

Are there any areas (feet, face, abdomen, etc) you do not want massaged?*

Yes

No

Where is your pain located?

Front

Back

Side

What are your treatment goals?*

By signing below, you agree to the following. I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time.

Please Print your First and Last Name*

Date*

Is the patient a minor?*

Yes

No

930 Bent Oak Ct
Lake St Louis, MO 63367

(636) 579-6908

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