Medical Massage Intake Form


Fields marked with an * are required

logo_russEdit_01Clinical Intake Form for Medical Massage

Please take the time to complete this form at least 24 hours prior to your appointment.  Answers to these questions allow us to provide the best assessment and treatment for your initial session.  There is no limit to the length of your responses when explanations might be needed.

If you have any questions, feel free to contact us or call 941-755-0406.


General Questions


Pain Evaluation

Examples: sharp, aching, burning, pulsating or describe in your own words.

Check all that apply.

Check all that apply.

1 - no pain, 10 - severe / unbearable

You are almost finished! Just a few more questions and you'll be on your way to making your medical massage appointment.


Evaluation of Sensory Abnormalities

Evaluation of Motor Abnormalities


When you click the submit button, our Medical Massage Therapist Team will review your responses and contact you within 24 hours of your submittal.  Congratulations on taking the first step in addressing your pain with medical massage and we look forward to meeting you soon!