Client Intake Form

This form helps me plan your massage session. Your responses send securely and privately — not stored on a server.

Personal Information

Your name (First Last)

Your email

Date of Birth (dd-mm-yyyy)

Gender
Male Female Other

Do you have an insurance?
Yes No

About Your Massage

Have you had a professional massage before?
Yes No

What type of massage are you looking for?
Therapeutic Relaxation Other
If "Other", you can describe below:

Preferred pressure:
Light Medium Deep

Your Lifestyle

Please, describe your Work environment:
Sedentary (office / desk job)
Lightly active (cashier, teacher, standing or light walking)
Moderately active (warehouse, delivery, on feet most of the day)
Highly active (athlete / construction)

Exercise or sports activity?
No Occasionally (1–2×/week) Regularly (3+×/week)

Medical Info

Do you have Fatigue / Stress / Emotional strain
None Occasionally (1–2×/week) Often (3–5×/week) Constant (daily)

Do you have any musculoskeletal issues to address:
Neck Shoulders Upper or Mid Back Lumbar Glutes Arms Legs Other

Do you have any traumas in the past:
No Yes

Please list any medical conditions relevant to massage:

Please confirm before submitting!
I do NOT have any of the following conditions: Tuberculosis, Syphilis, HIV/AIDS, Active Hepatitis, or STI

Additional information you'd like to share (optional):
Feel free to share what brings you here—whether it's tension seeking release, a mood you'd like to shift, or something your body’s been trying to tell you.

I am not allergic to dogs or plants, or I have allergies but can manage them myself.

Please note: in my massage clinic, you can customize many things to suit your preferences and needs for maximum effect. Pressure, pace, lighting, music, and more are all in your control. Feel free to share your ideas in the field above or discuss them on site.

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Andrew Sague — Registered Massage Therapist, CRMTAA License #001911.
Located in Calgary SE. Serving since 2020.