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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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.
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.