Happy Dog Massage Intake

Client Information for Massage

Please fill out the following questionnaire so that our Massage Therapist can better understand your needs.

Please select who will be receiving treatment?

Adult Minor(s)
1 Minor 2 Minors 3 Minors 4 Minors 5 Minors More Minors 6 Minors 7 Minors 8 Minors 9 Minors 10 Minors

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First Client Name

First Name*

Last Name*

First Client Age Acknowledgment*

First Client Date of Birth*

I certify that I am 18 years of age or older

First Client Information

Have you had a recent major surgical procedure?*

Yes

If yes, please explain:

Are you currently seeing a Chiropractor, Physical Therapist, or Physician for an ongoing issue?*

Yes

If yes, please explain:

What type of pressure do you prefer:*

What is your typical stress level?*

Are you taking any medication?*

Yes

If yes, please explain:

Please answer the questions below:

Do you have diabetes?*

Yes

Do you experience frequent headaches"*

Yes

Are you pregnant?*

Yes

Do you suffer from arthritis?*

Yes

Are you wearing dentures?*

Yes

Do you have high blood pressure and/or taking high blood pressure medication?*

Yes

Do you have varicose veins?*

Yes

Do you suffer from epilepsy or seizures?*

Yes

Do you suffer from joint swelling?*

Yes

Do you have osteoporosis?*

Yes

Do you have or have you had cancer?*

Yes

Do you have any allergies?*

Yes

Do you bruise easily?*

Yes

Any broken bones in the past two years?*

Yes

Do you have tension or soreness in a specific area?*

Yes

Do you have cardiac or circulatory problems?*

Yes

Do you suffer from back pain?*

Yes

Do you have any numbness or stabbing pains?*

Yes

Are you sensitive to touch or pressure in any area?*

Yes

If yes to ANY of the above, please explain:

Any other medical conditions the massage therapist should know about?*

Yes

If yes, please explain:

First Client Signature*

Type Signature

Draw Signature

Change Font

Accept Signature Clear

Click to Sign

Edit Signature

Second Client Name

First Name*

Last Name*

Second Client Date of Birth*

Second Client Information

Have you had a recent major surgical procedure?*

Yes

If yes, please explain:

Are you currently seeing a Chiropractor, Physical Therapist, or Physician for an ongoing issue?*

Yes

If yes, please explain:

What type of pressure do you prefer:*

What is your typical stress level?*

Are you taking any medication?*

Yes

If yes, please explain:

Please answer the questions below:

Do you have diabetes?*

Yes

Do you experience frequent headaches"*

Yes

Are you pregnant?*

Yes

Do you suffer from arthritis?*

Yes

Are you wearing dentures?*

Yes

Do you have high blood pressure and/or taking high blood pressure medication?*

Yes

Do you have varicose veins?*

Yes

Do you suffer from epilepsy or seizures?*

Yes

Do you suffer from joint swelling?*

Yes

Do you have osteoporosis?*

Yes

Do you have or have you had cancer?*

Yes

Do you have any allergies?*

Yes

Do you bruise easily?*

Yes

Any broken bones in the past two years?*

Yes

Do you have tension or soreness in a specific area?*

Yes

Do you have cardiac or circulatory problems?*

Yes

Do you suffer from back pain?*

Yes

Do you have any numbness or stabbing pains?*

Yes

Are you sensitive to touch or pressure in any area?*

Yes

If yes to ANY of the above, please explain:

Any other medical conditions the massage therapist should know about?*

Yes

If yes, please explain:

Third Client Name

First Name*

Last Name*

Third Client Date of Birth*

Third Client Information

Have you had a recent major surgical procedure?*

Yes

If yes, please explain:

Are you currently seeing a Chiropractor, Physical Therapist, or Physician for an ongoing issue?*

Yes

If yes, please explain:

What type of pressure do you prefer:*

What is your typical stress level?*

Are you taking any medication?*

Yes

If yes, please explain:

Please answer the questions below:

Do you have diabetes?*

Yes

Do you experience frequent headaches"*

Yes

Are you pregnant?*

Yes

Do you suffer from arthritis?*

Yes

Are you wearing dentures?*

Yes

Do you have high blood pressure and/or taking high blood pressure medication?*

Yes

Do you have varicose veins?*

Yes

Do you suffer from epilepsy or seizures?*

Yes

Do you suffer from joint swelling?*

Yes

Do you have osteoporosis?*

Yes

Do you have or have you had cancer?*

Yes

Do you have any allergies?*

Yes

Do you bruise easily?*

Yes

Any broken bones in the past two years?*

Yes

Do you have tension or soreness in a specific area?*

Yes

Do you have cardiac or circulatory problems?*

Yes

Do you suffer from back pain?*

Yes

Do you have any numbness or stabbing pains?*

Yes

Are you sensitive to touch or pressure in any area?*

Yes

If yes to ANY of the above, please explain:

Any other medical conditions the massage therapist should know about?*

Yes

If yes, please explain:

Fourth Client Name

First Name*

Last Name*

Fourth Client Date of Birth*

Fourth Client Information

Have you had a recent major surgical procedure?*

Yes

If yes, please explain:

Are you currently seeing a Chiropractor, Physical Therapist, or Physician for an ongoing issue?*

Yes

If yes, please explain:

What type of pressure do you prefer:*

What is your typical stress level?*

Are you taking any medication?*

Yes

If yes, please explain:

Please answer the questions below:

Do you have diabetes?*

Yes

Do you experience frequent headaches"*

Yes

Are you pregnant?*

Yes

Do you suffer from arthritis?*

Yes

Are you wearing dentures?*

Yes

Do you have high blood pressure and/or taking high blood pressure medication?*

Yes

Do you have varicose veins?*

Yes

Do you suffer from epilepsy or seizures?*

Yes

Do you suffer from joint swelling?*

Yes

Do you have osteoporosis?*

Yes

Do you have or have you had cancer?*

Yes

Do you have any allergies?*

Yes

Do you bruise easily?*

Yes

Any broken bones in the past two years?*

Yes

Do you have tension or soreness in a specific area?*

Yes

Do you have cardiac or circulatory problems?*

Yes

Do you suffer from back pain?*

Yes

Do you have any numbness or stabbing pains?*

Yes

Are you sensitive to touch or pressure in any area?*

Yes

If yes to ANY of the above, please explain:

Any other medical conditions the massage therapist should know about?*

Yes

If yes, please explain:

Fifth Client Name

First Name*

Last Name*

Fifth Client Date of Birth*

Fifth Client Information

Have you had a recent major surgical procedure?*

Yes

If yes, please explain:

Are you currently seeing a Chiropractor, Physical Therapist, or Physician for an ongoing issue?*

Yes

If yes, please explain:

What type of pressure do you prefer:*

What is your typical stress level?*

Are you taking any medication?*

Yes

If yes, please explain:

Please answer the questions below:

Do you have diabetes?*

Yes

Do you experience frequent headaches"*

Yes

Are you pregnant?*

Yes

Do you suffer from arthritis?*

Yes

Are you wearing dentures?*

Yes

Do you have high blood pressure and/or taking high blood pressure medication?*

Yes

Do you have varicose veins?*

Yes

Do you suffer from epilepsy or seizures?*

Yes

Do you suffer from joint swelling?*

Yes

Do you have osteoporosis?*

Yes

Do you have or have you had cancer?*

Yes

Do you have any allergies?*

Yes

Do you bruise easily?*

Yes

Any broken bones in the past two years?*

Yes

Do you have tension or soreness in a specific area?*

Yes

Do you have cardiac or circulatory problems?*

Yes

Do you suffer from back pain?*

Yes

Do you have any numbness or stabbing pains?*

Yes

Are you sensitive to touch or pressure in any area?*

Yes

If yes to ANY of the above, please explain:

Any other medical conditions the massage therapist should know about?*

Yes

If yes, please explain:

Sixth Client Name

First Name*

Last Name*

Sixth Client Date of Birth*

Sixth Client Information

Have you had a recent major surgical procedure?*

Yes

If yes, please explain:

Are you currently seeing a Chiropractor, Physical Therapist, or Physician for an ongoing issue?*

Yes

If yes, please explain:

What type of pressure do you prefer:*

What is your typical stress level?*

Are you taking any medication?*

Yes

If yes, please explain:

Please answer the questions below:

Do you have diabetes?*

Yes

Do you experience frequent headaches"*

Yes

Are you pregnant?*

Yes

Do you suffer from arthritis?*

Yes

Are you wearing dentures?*

Yes

Do you have high blood pressure and/or taking high blood pressure medication?*

Yes

Do you have varicose veins?*

Yes

Do you suffer from epilepsy or seizures?*

Yes

Do you suffer from joint swelling?*

Yes

Do you have osteoporosis?*

Yes

Do you have or have you had cancer?*

Yes

Do you have any allergies?*

Yes

Do you bruise easily?*

Yes

Any broken bones in the past two years?*

Yes

Do you have tension or soreness in a specific area?*

Yes

Do you have cardiac or circulatory problems?*

Yes

Do you suffer from back pain?*

Yes

Do you have any numbness or stabbing pains?*

Yes

Are you sensitive to touch or pressure in any area?*

Yes

If yes to ANY of the above, please explain:

Any other medical conditions the massage therapist should know about?*

Yes

If yes, please explain:

Seventh Client Name

First Name*

Last Name*

Seventh Client Date of Birth*

Seventh Client Information

Have you had a recent major surgical procedure?*

Yes

If yes, please explain:

Are you currently seeing a Chiropractor, Physical Therapist, or Physician for an ongoing issue?*

Yes

If yes, please explain:

What type of pressure do you prefer:*

What is your typical stress level?*

Are you taking any medication?*

Yes

If yes, please explain:

Please answer the questions below:

Do you have diabetes?*

Yes

Do you experience frequent headaches"*

Yes

Are you pregnant?*

Yes

Do you suffer from arthritis?*

Yes

Are you wearing dentures?*

Yes

Do you have high blood pressure and/or taking high blood pressure medication?*

Yes

Do you have varicose veins?*

Yes

Do you suffer from epilepsy or seizures?*

Yes

Do you suffer from joint swelling?*

Yes

Do you have osteoporosis?*

Yes

Do you have or have you had cancer?*

Yes

Do you have any allergies?*

Yes

Do you bruise easily?*

Yes

Any broken bones in the past two years?*

Yes

Do you have tension or soreness in a specific area?*

Yes

Do you have cardiac or circulatory problems?*

Yes

Do you suffer from back pain?*

Yes

Do you have any numbness or stabbing pains?*

Yes

Are you sensitive to touch or pressure in any area?*

Yes

If yes to ANY of the above, please explain:

Any other medical conditions the massage therapist should know about?*

Yes

If yes, please explain:

Eighth Client Name

First Name*

Last Name*

Eighth Client Date of Birth*

Eighth Client Information

Have you had a recent major surgical procedure?*

Yes

If yes, please explain:

Are you currently seeing a Chiropractor, Physical Therapist, or Physician for an ongoing issue?*

Yes

If yes, please explain:

What type of pressure do you prefer:*

What is your typical stress level?*

Are you taking any medication?*

Yes

If yes, please explain:

Please answer the questions below:

Do you have diabetes?*

Yes

Do you experience frequent headaches"*

Yes

Are you pregnant?*

Yes

Do you suffer from arthritis?*

Yes

Are you wearing dentures?*

Yes

Do you have high blood pressure and/or taking high blood pressure medication?*

Yes

Do you have varicose veins?*

Yes

Do you suffer from epilepsy or seizures?*

Yes

Do you suffer from joint swelling?*

Yes

Do you have osteoporosis?*

Yes

Do you have or have you had cancer?*

Yes

Do you have any allergies?*

Yes

Do you bruise easily?*

Yes

Any broken bones in the past two years?*

Yes

Do you have tension or soreness in a specific area?*

Yes

Do you have cardiac or circulatory problems?*

Yes

Do you suffer from back pain?*

Yes

Do you have any numbness or stabbing pains?*

Yes

Are you sensitive to touch or pressure in any area?*

Yes

If yes to ANY of the above, please explain:

Any other medical conditions the massage therapist should know about?*

Yes

If yes, please explain:

Ninth Client Name

First Name*

Last Name*

Ninth Client Date of Birth*

Ninth Client Information

Have you had a recent major surgical procedure?*

Yes

If yes, please explain:

Are you currently seeing a Chiropractor, Physical Therapist, or Physician for an ongoing issue?*

Yes

If yes, please explain:

What type of pressure do you prefer:*

What is your typical stress level?*

Are you taking any medication?*

Yes

If yes, please explain:

Please answer the questions below:

Do you have diabetes?*

Yes

Do you experience frequent headaches"*

Yes

Are you pregnant?*

Yes

Do you suffer from arthritis?*

Yes

Are you wearing dentures?*

Yes

Do you have high blood pressure and/or taking high blood pressure medication?*

Yes

Do you have varicose veins?*

Yes

Do you suffer from epilepsy or seizures?*

Yes

Do you suffer from joint swelling?*

Yes

Do you have osteoporosis?*

Yes

Do you have or have you had cancer?*

Yes

Do you have any allergies?*

Yes

Do you bruise easily?*

Yes

Any broken bones in the past two years?*

Yes

Do you have tension or soreness in a specific area?*

Yes

Do you have cardiac or circulatory problems?*

Yes

Do you suffer from back pain?*

Yes

Do you have any numbness or stabbing pains?*

Yes

Are you sensitive to touch or pressure in any area?*

Yes

If yes to ANY of the above, please explain:

Any other medical conditions the massage therapist should know about?*

Yes

If yes, please explain:

Tenth Client Name

First Name*

Last Name*

Tenth Client Date of Birth*

Tenth Client Information

Have you had a recent major surgical procedure?*

Yes

If yes, please explain:

Are you currently seeing a Chiropractor, Physical Therapist, or Physician for an ongoing issue?*

Yes

If yes, please explain:

What type of pressure do you prefer:*

What is your typical stress level?*

Are you taking any medication?*

Yes

If yes, please explain:

Please answer the questions below:

Do you have diabetes?*

Yes

Do you experience frequent headaches"*

Yes

Are you pregnant?*

Yes

Do you suffer from arthritis?*

Yes

Are you wearing dentures?*

Yes

Do you have high blood pressure and/or taking high blood pressure medication?*

Yes

Do you have varicose veins?*

Yes

Do you suffer from epilepsy or seizures?*

Yes

Do you suffer from joint swelling?*

Yes

Do you have osteoporosis?*

Yes

Do you have or have you had cancer?*

Yes

Do you have any allergies?*

Yes

Do you bruise easily?*

Yes

Any broken bones in the past two years?*

Yes

Do you have tension or soreness in a specific area?*

Yes

Do you have cardiac or circulatory problems?*

Yes

Do you suffer from back pain?*

Yes

Do you have any numbness or stabbing pains?*

Yes

Are you sensitive to touch or pressure in any area?*

Yes

If yes to ANY of the above, please explain:

Any other medical conditions the massage therapist should know about?*

Yes

If yes, please explain:

Parent or Guardian's Email Address

A signed copy of this waiver will be sent to the email address you provide.

Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.

By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.

Parent or Guardian's Name

First Name*

Last Name*

Parent or Guardian's Age Acknowledgment*

Parent or Guardian's Date of Birth*

I certify that I am 18 years of age or older

Parent or Guardian's Information

Have you had a recent major surgical procedure?*

Yes

If yes, please explain:

Are you currently seeing a Chiropractor, Physical Therapist, or Physician for an ongoing issue?*

Yes

If yes, please explain:

What type of pressure do you prefer:*

What is your typical stress level?*

Are you taking any medication?*

Yes

If yes, please explain:

Please answer the questions below:

Do you have diabetes?*

Yes

Do you experience frequent headaches"*

Yes

Are you pregnant?*

Yes

Do you suffer from arthritis?*

Yes

Are you wearing dentures?*

Yes

Do you have high blood pressure and/or taking high blood pressure medication?*

Yes

Do you have varicose veins?*

Yes

Do you suffer from epilepsy or seizures?*

Yes

Do you suffer from joint swelling?*

Yes

Do you have osteoporosis?*

Yes

Do you have or have you had cancer?*

Yes

Do you have any allergies?*

Yes

Do you bruise easily?*

Yes

Any broken bones in the past two years?*

Yes

Do you have tension or soreness in a specific area?*

Yes

Do you have cardiac or circulatory problems?*

Yes

Do you suffer from back pain?*

Yes

Do you have any numbness or stabbing pains?*

Yes

Are you sensitive to touch or pressure in any area?*

Yes

If yes to ANY of the above, please explain:

Any other medical conditions the massage therapist should know about?*

Yes

If yes, please explain:

Parent or Guardian's Signature*

Type Signature

Draw Signature

Change Font

Accept Signature Clear

Click to Sign

Edit Signature

Signature*

I agree that my intake form is up-to-date and understand that the details I have provided will be kept on file according to local laws.

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