Massage Intake Form
ADVERTISEMENT
1Massage 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
Have you had a professional massage before? ☐ yes ☐ no
☐ yes
☐ no
Are you taking any medications?
What type of massage are you seeking?
If yes, please list name and use: _____________________
☐ Relaxation
☐ Therapeutic/Deep Tissue
_______________________________________________
☐ yes
☐ no
Are you currently pregnant?
Other ___________________________________________
What pressure do you prefer?
If yes, how far along? ______________________________
☐ Light
☐ Medium
☐ Deep
Any high risk factors? ______________________________
☐ yes
☐ no
Do you suffer from chronic pain?
☐ yes ☐ no
Do you have any allergies or sensitivities?
If yes, please explain ______________________________
Please explain ________________________________
What makes it better? _____________________________
Are there any areas (feet, face, abdomen, etc.) you do not
☐ yes
☐ no
want massaged?
_______________________________________________
Please explain _______________________________
What makes it worse? ____________________________
What are your goals for this treatment session?
_______________________________________________
_____________________________________________
☐ yes
☐ no
Have you had any orthopedic injuries?
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 __________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business