Client Intake Form

Please complete all sections before your first massage session. This information helps your therapist personalize your treatment and ensure your safety and comfort.

Your health information is kept strictly confidential and used solely to provide safe, personalized massage therapy care.

Personal Information

First Name*

Last Name*

Date of Birth*

Phone Number*

Email Address*

Street Address

City

State

ZIP

Emergency Contact

Contact Name

Relationship

Phone Number

Health History

Primary Care Provider (name & practice)

Reason for Visit / Goals for Today's Session*

Current Medications (name & purpose)

Allergies (medications, topical products, latex, etc.)

Recent Surgeries, Injuries, or Accidents (past 12 months)

Pregnancy Status

Health Conditions

Please check all that apply. This helps your therapist adapt your session safely.

ArthritisAsthma / Respiratory issuesBlood clots / DVTCancer (current or history)Cardiovascular diseaseChronic painDiabetesFibromyalgiaHeadaches / MigrainesHigh blood pressureHIV / AIDSLupusMultiple sclerosisNeuropathyOsteoporosisPTSD / Anxiety / DepressionSkin conditionsStroke (history)Varicose veinsOther

Additional health notes or details

Massage Preferences

Pressure Preference

Areas to Focus On

Areas to Avoid

Previous Massage Experience

Additional Notes for Your Therapist

Fields marked * are required. Your information is kept strictly confidential.

Nurse Practitioner-led integrative health and wellness — bridging the gap between conventional medicine and holistic care.

Care For You. Prevent For Life.

Mind. Body. Balance. Relax. Restore. Renew.

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4641 Pottsville Pike Suite #106
Reading, PA 19605
484-529-6063
info@lifealignedcarebridge.com

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Ages 18+ · Private Pay & Insurance Accepted · In-Person & Telehealth