Massage Client Intake Form printable pdf download

Massage Client Intake Form

PLEASE PRINT LEGIBLY

Name _________________________________________ Email _________________________________

Address ______________________________________ City/State/Zip _________________________

Phone: Home______________Work_______________Cell_______________ Birthday ___/___/___

Occupation ________________________________ Referred to This Office By _________________

In Case of Emergency Please Contact ______________________________Phone______________

General and Medical Information

Have you ever had a professional massage?

If yes, how often?

Are you pregnant? If yes, how far along are you?

Are you sensitive to touch/pressure in any area? (ticklish?)

Are you allergic or sensitive to any oils (essential oils, nut oils, scents)? If yes, please list:

List of current medications and reason:

List of surgeries (type and date):

Indicate Areas of Pain/Tension:

On a scale from 1-10, 10=highest, rate your levels of:

Stress __ ____ Pain ___ ___ Energy ___ ___

How did your symptoms begin and when did they start?

________________________________________________________

What have you done for relief? _________________________

Is the condition getting better/worse? __________________

Please check all that apply:

Skin condition-rash, warts, hives, skin cancer,

other ___________________

Lymphatic condition-swollen gland, nasal congestion,

lymph edema

Joint problems/stiffness-arthritis, sacroiliac problems,

TMJ, other

Bone Condition-osteoporosis, fracture, other ______________

Headaches

Recent injury or accident-whiplash, sprain, bruise,

other _______________

Circulatory Condition-high blood pressure, varicose veins,

blood clots

Numbness/Tingling, Sciatica

Please mark in the diagram above any

Tendonitis, Bursitis

areas where you have pain or

Diabetes

discomfort.

Massage Client Intake Form