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Client Intake Form - Therapeutic Massage: City/State/Zip

This document is an intake form for a therapeutic massage client. It collects information such as the client's name, contact details, medical history, areas of tension or pain, massage goals and preferences. The client acknowledges that massage is not a substitute for medical treatment and agrees to update the therapist on any changes to their health that could impact the massage. The client also accepts full responsibility for any risks associated with the massage and holds the center harmless from any claims.

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Rick Tarleton
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100% found this document useful (1 vote)
110 views3 pages

Client Intake Form - Therapeutic Massage: City/State/Zip

This document is an intake form for a therapeutic massage client. It collects information such as the client's name, contact details, medical history, areas of tension or pain, massage goals and preferences. The client acknowledges that massage is not a substitute for medical treatment and agrees to update the therapist on any changes to their health that could impact the massage. The client also accepts full responsibility for any risks associated with the massage and holds the center harmless from any claims.

Uploaded by

Rick Tarleton
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Client Intake Form Therapeutic Massage

Name Phone (Day) Cell


Address City/State/Zip
Email Occupation
Date of Birth Referred by
Emergency Contact Phone
The following information will be used to help your therapist plan a safe and effective
massage session. Please answer the uestions to the best of your knowledge.
Have you had a professional massage before? Yes No If yes, how often?
Do you have any difficulty lying on your front, back, or side? Yes No
If yes, please explain
Do you have any allergies to oils, lotions, ointments, fruits or nuts? Yes No
If yes, please explain
Do you have sensitive skin? Yes No
Are you wearing D contact lenses D hearing aid D prosthetics?
Do you sit for long hours at a workstation, computer, or driving? Yes No
If yes, please describe
Do you perform any repetitive movement in your work, sports, or hobby? Yes No
If yes, please describe
How do you feel the stress in your work, family, or other aspect of your life affected your health?
D muscle tension D anxiety D insomnia D irritability D other
Is there a specific area of the body where you are experiencing tension, stiffness, pain or discomfort?
Yes No If yes, please identify
Do you have any particular goals in mind for this massage session? Yes No
If yes, please explain
Circle any specific areas you would like the massage therapist to concentrate on during the session:
Medical !istory
"o you currently or have you ever had any of the following# $please check%
D phlebitis D tennis elbow
D deep vein thrombosis/blood clots D recent fracture
D joint disorder D recent surgery
D rheumatoid arthritis/osteoarthritis/tendonitis D artificial joint
D osteoporosis D sprains/strains
D epilepsy D current fever
D headaches/migraines D swollen glands
D cancer D allergies/sensitivity
D diabetes D heart condition
D decreased sensation D high or low blood pressure
D back/neck problems D circulatory disorder
D Fibromyalgia D varicose veins
D TMJ D atherosclerosis
D carpal tunnel syndrome D easy bruising
D contagious skin condition D recent accident or injury
D open sores or wounds D pregnancy If yes, how many months?
Are you currently under medical supervision? Yes No
If yes, please explain
Do you see a chiropractor? Yes No If yes, how often?
Are you currently taking any medication? Yes No
If yes, please list
Is there anything else about your health history that you think would be useful for your massage therapist
to know to plan a safe and effective massage session for you?
I 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 my 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 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 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 therapists part should I fail to do so.
I accept full responsibility for my use of any and all apparatus, appliances, facility privelage or service
whatsoever, owned and operated by this Center at my own risk and shall hold this Center, its shareholders,
directors, officers, employees, representatives, and agents harmless from any and all loss, claim, injury,
damage, negligence or liabilty sustained or incured by me resulting therefrom.
Signature of client Date
Gratuities are not included in the price of the treatment. Tips are not expected, but are appreciated.

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