First visit

Client intake form.

Health history, pressure preference and areas of focus. Fill it in before your first session so the whole time goes to your body. It takes about five minutes.

Your answers go only to Grëg.

1About you

First name *Last name *Email *Phone *Birthday *Address *

Emergency contact

Name *Number *Relationship *

How did you hear about us?Yes, subscribe me to your newsletter.

2Medical information

Are you taking any medication? *

Yes No

Please list them

Are you currently pregnant? *

Yes No

How far along?Are there any risk factors?

Do you suffer from chronic pain? *

Yes No

Please explain in detail

What makes it better?What makes it worse?

Do you have any injuries?

Yes No

Please explain

Please indicate any of these conditions that apply to you *

CancerHeadaches/MigrainesArthritisDiabetesJoint Replacement(s)High/Low Blood PressureNeuropathyFibromyalgiaStrokeHeart AttackKidney DysfunctionBlood ClotsNumbnessSprains or StrainsN/AOther

Other condition

3Massage information

Have you ever received a professional massage before? *

Yes No

What type of massage are you seeking?

RelaxationTherapeutic/Deep TissueOther

Other

What type of pressure do you prefer?

LightMediumDeep

Do you have any allergies or sensitivities?

Yes No

Please list them

Please select any areas of discomfort or tenderness *

HeadNeckFaceShouldersArmsHandsUpper BackLower BackButtocks/HipsUpper legKneesLower legAnkle/FootStomachChest

Are there any areas you don't want massaged? If yes, please list them.Please explain any conditions or areas of discomfort you have marked above

4AgreementI have completed this form to the best of my ability, and I agree to inform my therapist if any of the above information changes. *

Print name *Date *

Signature: type your full name *

Typing your name here counts as your signature.

Received

Thank you. Your form is with Grëg.

He'll read it before your session. If anything changes, just let him know.

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Indigenous Massage

Creating more space in your body for you to live. Mobile massage across Los Angeles since 2016.

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(818) 877-3373
gregory@indigenousmassage.com
North Hollywood, Los Angeles, CA 91606
Open every day, 8am–8pm

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