Scribd
Upload
777 views1 page

Intake Form

This massage intake form collects personal and medical information from a new client. It requests contact details, medical history including medications, injuries, and conditions. It asks about massage experience and preferences for pressure and areas to avoid. The client signs agreeing to provide accurate information and update the therapist if anything changes. The therapist also signs agreeing to the information disclosed.

Uploaded by

api-358259684
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
777 views1 page

Intake Form

This massage intake form collects personal and medical information from a new client. It requests contact details, medical history including medications, injuries, and conditions. It asks about massage experience and preferences for pressure and areas to avoid. The client signs agreeing to provide accurate information and update the therapist if anything changes. The therapist also signs agreeing to the information disclosed.

Uploaded by

api-358259684
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
You are on page 1/ 1

Massage Intake Form

Personal Information
Name ________________________________________ Phone (day) _____________________ (evening) _____________________

Address _____________________________________ City/State/Zip _________________________________ DOB ___________

Occupation _____________________________________________ Employer ___________________________________________

Email _______________________________________________ Primary Physician _______________________________________

Emergency Contact ____________________________________ Relationship __________________ Phone __________________

How did you hear about us? ____________________________________________________________________________________

Medical Information Massage Information


Are you taking any medications? yes no Have you had a professional massage before? yes no
If yes, please list name and use: _____________________ What type of massage are you seeking?
_______________________________________________ Relaxation Therapeutic/Deep Tissue
Are you currently pregnant? yes no Other ___________________________________________
If yes, how far along? ______________________________ What pressure do you prefer?
Any high risk factors? ______________________________ Light Medium Deep
Do you suffer from chronic pain? yes no Do you have any allergies or sensitivities? yes no
If yes, please explain ______________________________ Please explain ________________________________
What makes it better? _____________________________ Are there any areas (feet, face, abdomen, etc.) you do not
_______________________________________________ want massaged? yes no
Please explain _______________________________
What makes it worse? ____________________________
What are your goals for this treatment session?
_______________________________________________
_____________________________________________
Have you had any orthopedic injuries? yes no
Please circle any areas of discomfort
If yes, please list: ________________________________
Please indicate any of the following that apply to you.

Cancer Fibromyalgia
Headaches/Migraines Stroke
Arthritis Heart Attack
Diabetes Kidney Dysfunction
Joint Replacement(s) Blood Clots
High/Low Blood Pressure Numbness
Neuropathy Sprains or Strains

By signing below you agree to the following.


Explain any conditions you have marked above: I have completed this form to the best of my ability and knowledge
and agree to inform my therapist if any of the above information
________________________________________________
changes at any time.
________________________________________________
________________________________________________ Client Signature __________________________ Date __________

________________________________________________ Therapist Signature _______________________ Date __________

You might also like