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Massage Intake Form Template 12

This document is a massage intake form collecting personal and medical information from a new client. It requests contact details, medical history including medications, injuries, conditions, and pregnancy status. 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 of any changes.

Uploaded by

Hazel Roda Estorque
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOC, PDF, TXT or read online on Scribd
163 views

Massage Intake Form Template 12

This document is a massage intake form collecting personal and medical information from a new client. It requests contact details, medical history including medications, injuries, conditions, and pregnancy status. 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 of any changes.

Uploaded by

Hazel Roda Estorque
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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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 have any allergies or sensitivities? ☐ yes ☐ no
Do you suffer from chronic pain? ☐ 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
__________

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