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

About Your Massage

Have you had a professional massage before?
No Rare Regularly

What type of massage are you looking for?
Therapeutic Relaxation Other

If "Other", describe:


Preferred pressure:
Light Medium Deep

Your Lifestyle

Work environment
Sedentary Physical work Mixed

Repetitive motions at work?
Yes No

Do you experience discomfort at work?
Not at all Rarely Frequently

Exercise or sports activity?
No Rarely Regularly

Medical Info

Musculoskeletal issues to address:


Trauma in the past:
No Minor Major

Please listed here ant existing illnesses:


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.


Submit