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Massage Client Intake Form: Personal Information

This massage client intake form collects personal information such as name, address, contact details, date of birth, height, weight, exercise habits, smoking history, and medication use. It asks about the client's medical history including previous injuries, surgeries, and complaints. The form inquires about the client's goals for massage therapy and preferred pressure. It identifies potential health issues or contraindications for massage therapy and has the client mark any areas of discomfort on a diagram. The client signs to acknowledge massage is for relaxation and not a medical diagnosis.

Uploaded by

Treicy Aguilera
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142 views1 page

Massage Client Intake Form: Personal Information

This massage client intake form collects personal information such as name, address, contact details, date of birth, height, weight, exercise habits, smoking history, and medication use. It asks about the client's medical history including previous injuries, surgeries, and complaints. The form inquires about the client's goals for massage therapy and preferred pressure. It identifies potential health issues or contraindications for massage therapy and has the client mark any areas of discomfort on a diagram. The client signs to acknowledge massage is for relaxation and not a medical diagnosis.

Uploaded by

Treicy Aguilera
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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Massage Client Intake Form

Personal Information
Name: Date:
Address:
City: State: Zip:
Phone: Email:
DOB: Age:
Sex: Height: Weight:
History
Exercise Frequency: Exercise Type(s):
Do you smoke? Have you ever smoked? How Often?
How much water do you drink per day?
What medications are you currently using?
Previous complaints/surgeries/medications:
What is your major complaint?
Have you received massage therapy before?
Goals for massage therapy today? Relaxation Rehabilitation High activity level maintenance
Preferred type of touch: Light/Meditative Heavy/Invigorating Deep/Trigger Point
Do You Have Any of the Following Today? (Check All That Apply)
Sunburn Cuts, Burns, Bruises Inflammation Irritated Skin Rash
Headache Severe Pain Poison Ivy Cold or Flu
Asthma Arteriosclerosis Pregnancy Arthritis
Diabetes Varicose Veins Hernia Stomach Ulcers
Epilepsy Dizziness Cancer Pins/Pacemaker
Depression High Blood Pressure Contact Lenses Heart Disease
Hemophilia Low Blood Pressure Musculoskeletal Problems
Mark Areas of Discomfort

I understand that massage is designed for the purpose of relaxation and relief from tension, muscle spasms or
poor circulation. The massage therapist cannot diagnose medical issues/diseases/disorders or perform spine
palpitations.

Signature Date
www.FreePrintableMedicalForms.com

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