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Massage by Machelle

Your Wellness Journey Starts Here

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machellewest1629@gmail.com

(636) 579-6908

Intake Form

Please complete the following form or click here to print & complete prior to your visit.

Massage By Machelle Intake Form

Full Name

Phone (day)

Phone (evening)

Street Address

City

State

Zip Code

Occupation

Email

Emergency Contact

Employer

Primary Physician

Relationship

How did you hear about us?

Medical Information

Massage Information

Are you taking any medcations? *

Yes

No

Have you had a professional massage before? *

Yes

No

If yes, please list name and use:

What Type of Massage Are You Seeking?

Are you currently pregnant? *

Yes

No

n/a

If yes, how far along

What pressure do you prefer? *

Light

Medium

Deep

Do you have any allergies or sensitivities? *

Yes

No

Do you suffer from chronic pain? *

Yes

No

If yes, please explain

If yes, please explain.

What makes it better?

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

Yes

No

What makes it worse?

If yes, please explain

Have you had any orthopedic injuries? *

Yes

No

If yes, please list

Explain any conditions you have tha we should know about.

What are your goals for this treatment session?

Please indicate FRONT RIGHT areas of pain

none of these

forehead

right shoulder

right chest

right bicep

right upper abdomen

right elbow

right forearm

right lower abdomen

right hip

right wrist/hand

right thigh

right knee

right shin

right ankle

right foot

Please indicate FRONT LEFT areas of pain

none of these

sinus

left shoulder

left chest

left bicep

left upper abdomen

left elbow

left forearm

left lower abdomen

left hip

left wrist/hand

left thigh

left knee

left shin

left ankle

left foot

Please indicate BACK LEFT areas of pain

none of these

base of skull

left neck

left shoulder

left upper back

left tricep (backside of bicep)

left middle back

left elbow

left forearm

left lower back

left buttock

left wrist/hand

left back thigh

left back knee

left back calf

left heel

left bottom of foot

Please indicate BACK RIGHTareas of pain

none of these

top/back of head

right neck

right shoulder

right upper back

right tricep (backside of bicep)

right middle back

right elbow

right back forearm

right lower back

right buttock

right wrist/hand

right back thigh

right back knee

right back calf

right heel

right bottom of foot

Please indicate LEFT SIDE areas of pain

none of these

left side head

left temple

left jaw

left neck

left side of shoulder

left side of arm

left elbow

left ribcage

left wrist/hand

left side of thigh

left side of knee

left side of calf

left side of ankle

left side of foot

Please indicate RIGHT SIDE areas of pain

none of these

right side head

right temple

right jaw

right neck

right side of shoulder

right side of arm

right elbow

right ribcage

right wrist/hand

right side of thigh

right side of knee

right side of calf

right side of ankle

right side of foot

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

Please Print Your First and Last Name:

If patient is a minor, parent or guardian, ples sign here:

Today's Date

Today's Date

Thanks for submitting!

930 Bent Oak Ct
Lake St Louis, MO 63367

(636) 579-6908

©2023 by Massage by Machelle.

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