Intake Form

Please fill out the following form after your first massage appointment is confirmed.
I REQUIRE A 3 HOUR NOTICE FOR CANCELLATION. OTHERWISE, PAYMENT IS EXPECTED.

Personal Information

Name

Phone

Email Address

How did you hear about Zen Deep Massage?

Medical Information

Are you taking any medications?

If yes, please list name and use:

Are you currently pregnant?

If yes, how far along?

List any high risk factors:

Do you suffer from chronic pain?

If yes, please explain:

What makes it better?

What makes it worse?

Have you had any orthopedic injuries?

If yes, please explain:

Please indicate any of the following that apply to you.

CancerHeadaches/MigrainesArthritisDiabetesJoint Replacement(s)High/Low Blood SugarNeuropathyFibromyalgiaStrokeHeart AttackKidney DysfunctionBlood ClotsNumbnessSprains or Strains

Explain any conditions you have marked:

Massage Information

Have you had a professional massage before?

What type of massage are you seeking?

What pressure do you prefer?

Do you have any allergies or sensitivities?

If yes, please explain:

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

If yes, please explain:

What are your goals for this treatment session?

By hitting "submit", 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.