Massage Therapy in Carol Stream | Bodywork Designed for Balance

Intake Form

Please complete your intake form before your appointment.

Intake Form

First Name

Last Name

Date of Birth

Email

Phone

Address

Emergency Contact

Emergency Phone

Have you had a professional massage before?

Yes

No

Primary reason for today’s visit:

If Other, please enter details here

Please explain any checked conditions:

If yes, please describe (include dates if possible):

Are you currently taking any medications?

Yes

No

If yes, please list:

Are you currently pregnant?

Yes

No

Have you had any recent injuries or surgeries?

Yes

No

If yes, how many weeks?

Daily stress level:

Low

Moderate

High

Activity level:

Sedentary

Lightly active

Active

Very active

Hydration level:

Low

Moderate

High

Pressure preference:

Low

Medium

Firm

Deep

Focus areas for today’s session:

Areas to avoid:

CONSENT & ACKNOWLEDGEMENT

CONSENT & ACKNOWLEDGEMENT

Opt-In

I understand that massage therapy is intended for relaxation and therapeutic purposes and is not a substitute for medical treatment.

Opt-In

I have disclosed all known medical conditions and will inform my therapist of any changes.

Opt-In

I understand that I may stop or modify the session at any time.

Opt-In

I consent to receive massage therapy.

Opt-In

I understand that any inappropriate behavior will result in immediate termination of the session.

Client Signature

Signature Date