Bodylogic Massage Studio

Patient Intake Form

Personal Information

Name Prefix

First Name

Last Name *

Address Type

Address Country

Address 1 *

Address 2

Address City *

Address State

Address Zip Code *

Phone Type

Phone Country

Phone Number *

Phone Extension

Email Type

Email *

Occupation

Marital Status

Referred By

Emergency Contact Name

Phone Type 1

Phone Country 1

Emergency Contact Phone *

Phone Extension 1

Date of Birth

Massage Experience

Have you had a professional massage before?

Yes

If Yes, what types of massage have you had (swedish, shiatsu, deep tissue, etc.)?

How long have you been receiving massage therapy?

Frequency of massages?

What are your goals for treatment?

Current Health

Do you exercise regularly and/or participate in any sports?

Yes

If yes, what kind of exercise/sports?

Do you perform any repetitive movement in your work, sports or hobby?

Yes

If yes, describe

Do you sit for long hours at a workstation, computer or driving?

Yes

If yes, describe

Do you experience stress in your work, family, or other aspect of your life?

Yes

If yes, describe

Are you experiencing tension, stiffness, discomfort of pain?

Yes

If yes, describe

Have you recently had an injury, surgery, or areas of inflammation?

Yes

If yes, describe

Do you have sensitive skin?

Yes

Do you have any allergies to oils, lotions or ointments?

Yes

If yes, describe

List any medications you are currently taking

List any known allergies

Health History

Musculoskeletal

Bone or Joint Disease	Tendonitis/Bursitis	Arthritis/Gout
Jaw Pain (TMJ)	Lupus	Spinal Problems
Migraines/Headaches	Osteoporosis

Circulatory

Heart Condition	Phlebitis/Varicose Veins	Blood Clots
High/Low Blood Pressure	Lymphedema	Thrombosis/Embolism

Respiratory

Breathing Difficulty/Asthma	Emphysema	Sinus Problems
Allergies

If Allergies, please specify:

Nervous System

Shingles

Numbness/Tingling

Pinched Nerve

Chronic Pain

Paralysis

Multiple Sclerosis

Parkinson's Disease

Reproductive

Ovarian/Menstrual Problems

Prostate

Pregnant

If Pregnant, what stage?

Skin

Rashes

Cosmetic Surgery

Athlete's Foot

Herpes/Cold Sores

Allergies

If Allergies, specify:

Digestive

Irritable Bowel Syndrome

Bladder/Kidney Ailment

Colitis

Crohn's Disease

Ulcers

Psychological

Anxiety/Stress Syndrome

Depression

Other

Cancer/Tumors

Diabetes

Drug/Alcohol/Tobacco Use

Contact Lenses

Dentures

Hearing Aids

Any other medical condition(s) not listed:

Please explain any of the conditions that you have marked above:

Digital Signature

I agree that the above information is correct and accurate

Hours: M-F 8 am - 7 pm

Sat by appointment only

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Phone: 605.836.0021 Email: info@bodylogicmassagesf.com

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