Massage Therapy Intake Form Personal InformationYou will receive a copy of the information using the email provided.Name(Required) Phone (day)(Required)Phone (evening)Address(Required) City/Province(Required) DOB(Required) MM slash DD slash YYYY Occupation Employer Email(Required) Primary Physician(Required) Meadowlands Physiotherapy sends email communication for your physiotherapy care which includes health screenings, appointment remidners and personalized exercise plans. When possible, please use your personal email. Please avoid using your work email, as our correspondence includes personal health information Yes, I also want email updates on workshop and class schedules, and tips from Meadowlands Physiotherapy Emergency Contact(Required) Relationship(Required) Phone(Required)How did you hear about us? Medical InformationAre you taking any medications?(Required) Yes No If yes, please list name and use: Are you currently pregnant?(Required) Yes No If yes, how far along? Any high risk factors? Do you suffer from chronic pain?(Required) Yes No If yes, please explain: What makes it better? What makes it worse? Have you had any orthopedic injuries?(Required) Yes No If yes, please list: Please indicate any of the following that apply to you.(Required) Cancer Headaches/Migraines Arthritis Diabetes Join Replacement(s) High/Low Blood Pressure Neuropathy Fibromyalgia Stroke Heart Attack Kidney Dysfunction Blood Clots Numbness Sprains or Strains None of the above Explain any conditions you have checked above:Massage InformationHave you had a professional massage before(Required) Yes No What type of massage are you seeking?(Required) Relaxation Therapeutic / Deep Tissue Other What pressure do you prefer?(Required) Light Medium Deep Other Do you have any allergies or sensitivities?(Required) Yes No Please explain Are there any areas (feet, face, abdomen, etc.) you do not want massaged?(Required) Yes No Please explain What are your goals for this treatment session?(Required) Please explain any areas of discomfortExamples are left side of neck, right side lower back, right ankle. By digitally 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. Client Signature(Required) Reset signature Signature locked. Reset to sign again Date MM slash DD slash YYYY
