Airmid Massage
Exceptional massage conveniently located in downtown La Crescent, MN!

Client Forms

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Airmid Massage


intake FORM


(Please Print)

Today’s date:





Email address:







How did you find me?

-Word of mouth (list who):


- Internet

- Other (please list):




Date of Birth:                      Occupation:                

Are you currently under care for a chronic illness? If yes, please explain: ________________________________________________________________

Health care provider:________________________________________________

Please list any medications or dietary supplements: ________________________________________________________________________________________________________________________________

Have you received massage before? Y/N If yes, how often? ________________

Goals for massage: ________________________________________________

List Areas of Pain and Tension:_______________________________________

List any allergies or sensitivities:_______________________________________

Are you sensitive to oils or fragrances? If so, which?

Do you have any areas you wish I would avoid during massage?



Health Information please mark an X on anything that applies:

_Abdominal/digestive problems    _Depression                             _ Numbness/Tingling

_ Allergies                                     _ Diabetes                                _ Pregnancy

_ Anxiety                                       _ Epilepsy/seizure disorder      _ Sinus Problems

_ Arthritis/Tendonitis                      _ Fatigue                                 _ Sleep disturbance (list below)

_ Asthma/Lung condition               _ Headaches/Migraine            _ Sleep Apnea

_ Athletes Foot/Fungal disease     _ Hernia                                   _ Sprain/Strain

_ Blood Clots                                 _ High Blood Pressure             _ Tension/stress

_ Chronic pain                               _ Jaw Pain/ TMJ                       _ Vision problems

_ Constipation/diarrhea                 _ Low Blood Pressure              _ Varicose Veins

_ Chron’s Disease                        _ Muscle/Bone Injuries

_ Circulation problems                  _ Muscles/Joint Pain

_ Cancer/tumors                           _ Myofascial pain syndrome/Fibromyalgia

Please list any other medical issues: ____________________________________________________________________________________________________________________________________________________________________

List any recent or past injuries and the time it occurred: _____________________________________  


List previous surgeries: _______________________________________________________________


Are you wearing contacts? Y/N          

What are your hobbies?


List pet peeves in regard to massage therapy (It’s ok to be very honest here, I want to provide the best experience possible for you): __________________________________________________________


By signing this form, I concede that all the information listed is accurate. I consent to massage therapy and will inform the massage therapist of any changes in my health information to the best of my ability. I am aware that massage therapists use hands-on techniques to relieve pain and tension and that it is not within their scope to diagnose and prescribe. I am fully aware that if massage is contraindicated at any time that the massage therapist has the right to refuse service and refer to a physician.

Signature:                                                       Date: