Massage Intake Form — Wilder Wellness Consulting

Full & preferred name

Email

Phone

Date of birth

Who is this intake for

Adult, child, or infant — and their age, if applicable.

Emergency contact (name & number)

Health history

Share as much or as little as you feel comfortable sharing.

General health history

Current symptoms & concerns

Surgeries, injuries & accidents

Medications, supplements & herbs

Allergies & skin sensitivities

Pregnant or postpartum?

If so, how far along or how long since birth.

Areas of pain or tension

Areas to focus on — or avoid entirely

Pressure preference

Past experience with massage or bodywork

SCENTS & PREFERENCES

MUSIC & SOUNDPREFERENCES

What you would like to work toward

Anything else I should know