Massage Intake Form

New patients can begin by filling out the two-part form below. This form addresses: 1) Self Evaluation and 2) Patient Information. Once we receive your inquiry, our office will be in touch with you to schedule a first appointment. New clients can also call our office at 510-452-2929 to get started.

  1. 1. Self Evaluation

    Please select the areas on which you would like to focus
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  5. Select Yes or No for each question. If you answer yes, please explain below. (All answers are required.)
  6. Do you often experience stress?
  7. Do you often experience anxiety?
  8. Do you often experience depression?
  9. Do you have frequent headaches?
  10. Do you have any allergies?
  11. Do you have osteoporosis?
  12. Do you suffer from arthritis?
  13. Do you have edema/swelling?
  14. Do you have tendonitis?
  15. Do you suffer from back/neck pain?
  16. Do you have epilepsy or seizures?
  17. Do have numbness or tingling?
  18. Do have chronic pain?
  19. Do have spasms or cramps?
  20. Do you often feel fatigued?
  21. Do you bruise easily?
  22. Do you have any respiratory difficulties?
  23. Do you have any digestive disorders?
  24. Do you have diabetes?
  25. Do you have varicose veins?
  26. Any heart/circulation problems?
  27. Do you have high/low blood pressure?
  28. Do you have blood clots?
  29. Have you ever had surgery?
  30. Any rashes or open skin wounds?
  31. Do you have any contagious diseases?
  32. Any skin or other type of cancer?
  33. Any injuries in the past two years?
  34. Are you pregnant?

  35. 2. Patient Information

    * Fields marked with an asterisk are required.

    General Information
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  39. (valid email required)
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  45. Will you be submitting receipts to your insurance company for reimbursement?*
  46. What is the best method to remind of future appointments?