Client Intake Form - Therapeutic Massage

Personal Information:

Name(Required)

Phone (Day)(Required)

Phone (Eve)(Required)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Date of Birth(Required)

Occupation

Emergency Contact(Required)

Phone(Required)

The following information will be used to help plan safe and effective massage sessions. Please answer the questions to the best of your knowledge.

Date of Initial Visit

Have you had a professional massage before?

Yes

If yes, how often do you receive massage therapy?(Required)

Do you have any difficulty lying on your front, back, or side?

Yes

If yes, please explain(Required)

Do you have any allergies to oils, lotions, or ointments?

Yes

If yes, please explain(Required)

Do you have sensitive skin?

Yes

Are you wearing contact lenses?

Dentures

A Hearing Aid

Do you sit for long hours at a workstation, computer, or driving?

Yes

If yes, please describe(Required)

Do you perform any repetitive movement in your work, sports, or hobby?

Yes

If yes, please describe(Required)

Do you experience stress in your work, family, or other aspect of your life?

Yes

If yes, how do you think it has affected your health?(Required)

Is there a particular area of the body where you are experiencing tension, stiffness, pain or other discomfort?

Yes

If yes, please identify(Required)

Do you have any particular goals in mind for this massage session?

Yes

If yes, please explain(Required)

Circle any specific areas you would like the massage therapist to concentrate on during the session:

Medical History

In order to plan a massage session that is safe and effective, I need some general information about your medical history.

Are you currently under medical supervision?

Yes

If yes, please explain(Required)

Do you see a chiropractor?

Yes

If yes, how often?(Required)

Are you currently taking any medication?

Yes

If yes, please list(Required)

Please check any condition listed below that applies to you:

Please explain any condition that you have marked above(Required)

Is there anything else about your health history that you think would be useful for your massage practitioner to know to plan a safe and effective massage session for you?

Draping will be used during the session – only the area being worked on will be uncovered.

Clients under the age of 17 must be accompanied by a parent or legal guardian during the entire session. Informed written consent must be provided by parent or legal guardian for any client under the age of 17.

print name

understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so.

Signature of client(Required)

Date(Required)

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Client Intake Form (Online)

Client Intake Form - Therapeutic Massage

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