Therapeutic Massage Client Intake Form printable pdf download

Client Intake Form – Therapeutic Massage

Name___________________________ Phone (Day) ___________________Cell____________________

City/State/Zip______________________________

Address______________________________________

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 questions 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

If yes, please explain ______________________________________________________________

Do you have any allergies to oils, lotions, ointments, fruits or nuts?

Yes

If yes, please explain ______________________________________________________________

Do you have sensitive skin?

Yes

Are you wearing

contact lenses

dentures

a hearing aid

prosthetics?

Do you sit for long hours at a workstation, computer, or driving?

Yes

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?

muscle tension

anxiety

insomnia

irritability

other___________________

Is there a specific area of the body where you are experiencing tension, stiffness, pain or discomfort?

Yes

If yes, please identify____________________________________________________

Do you have any particular goals in mind for this massage session?

Yes

If yes, please explain______________________________________________________________

Circle any specific areas you would like the massage therapist to concentrate on during the session:

Therapeutic Massage Client Intake Form