Spa Mobile Medical Intake Form

Please take a few minutes to complete this confidential medical form to help us personalize your session and ensure your safety. Your answers will be shared only with your assigned massage therapist.

Client Info

First Name *

Last Name *

Phone *

Email *

Date of birth *

Appointment Info

The information below helps us correctly link your medical file to your appointment and ensures that it is shared only with the massage therapist you are booked with.

Massage therapist’s name *

Appointment date and time *

Who booked this appointment? *

General Lifestyle

Occupation *

What best describes your daily activity or posture? *

Dominant hand *

Right-handed / Droitier(ère)

Left-handed / Gaucher(ère)

Ambidextrous / Ambidextre

Do you exercise regularly? *

Yes / Oui

No / Non

🔽 If "Yes" is selected

Which types of exercise do you do more than twice a week?

On a scale from 1 to 10, how would you rate your average stress level?

1 = Very low stress / 10 = Extremely high stress

How many hours of sleep do you usually get per night? *

Approximate number of hours

Health History

Do you currently have or have had any of the following conditions? *

Check all that apply

If other condition , please specify

Are you currently taking any medication? *

Yes / Oui

No / Non

Medication - If yes, please list

Do you have any allergies or sensitivities? *

If none, write "None"

Do you have any past injuries, surgeries, or areas of chronic pain? *

This helps your therapist avoid sensitive areas and adjust pressure as needed. If none, write "None"

Is there anything else your therapist should know before your session?

Consent and Waiver

By submitting this form, I confirm and agree to the following:

I authorize the use of lotions, oils, and ointments during my massage session.
I understand that massage therapy is an alternative treatment and does not replace medical care. If I have any medical concerns, I agree to consult my physician.
I acknowledge that this massage is strictly non-sexual, and any inappropriate behavior or touching of the therapist is strictly prohibited.
I release Spa Mobile and its massage therapists from any liability in case of accident, illness, allergic reaction, or injury that may occur during or after the session.
I confirm that all the information provided in this form is true and accurate.
If I have a medical condition, I confirm that I have consulted my physician prior to receiving massage therapy.

I agree to the above consent and waiver.