Massage Therapy Intake Form

Are you a patient at Frain Family Chiropractic or Laser Therapy of Green Bay?

Yes. (Please skip to the "Medical Information" section of this form.)

No. (Please complete the following personal information.)

Emergency Contact Name

Emergency Contact Phone Number

How did you hear about us?

Walk In/Friend

Google

Facebook

Other

Medical Information

Please list all medications, including over the counter medications:

Are you pregnant?

Yes

If yes, how far along are you?

Are there any high risk factors?

Do you suffer from chronic pain?

Yes

If yes; please describe:

What makes the discomfort better? (Check all that apply.)

What makes the discomfort worse? (Check all that apply.)

Have you had any orthopedic injuries?

Yes

If yes, please explain:

Please check any/all conditions you have had or currently have.

Massage Information

Have you had a professional massage in the past?

Yes

What type of massage are you seeking?

Relaxation

Therapeutic/Deep Tissue

What pressure do you prefer?

Light

Medium

Deep

Do you have any allergies or sensitivities?

Yes

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

Yes

What are your goals for your session?

Mark whichever number correlates to the area(s) of complaints on the graphic above

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By 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.

I understand that payment in full is due at the time services are rendered.