Client Intake Form - Therapeutic Massage
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2Client Intake Form – Therapeutic Massage
Personal Information:
Name: ____________________________________________
Phone (Day): _______________________________
Address: __________________________________________
Phone (Eve): _______________________________
City: ______________________________________________
State / Zip:
_______________________________
Email: _____________________________________________
Date of Birth: _______________________________
Employer: __________________________________________
Occupation: _______________________________
Emergency Contact: _______________________________
Phone #:
_______________________________
(The following information will be used to help plan safe and effective massage sessions. Please answer the questions to the best of your
Initial Visit Date: ______________________________
knowledge.)
1. Have you had a professional massage before?
Yes
No
If yes, how often do you receive massage therapy? ___________________________________________________
2. Do you have any difficulty lying on your front, back, or side?
Yes
No
If yes, please explain _________________________________________________________________________________
3. Do you have any allergies to oils, lotions, or ointments?
Yes
No
If yes, please explain _________________________________________________________________________________
4. Do you have sensitive skin?
Yes
No
5. Are you wearing contact lenses ( )
dentures ( )
a hearing aid ( ) ?
6. Do you sit for long hours at a workstation, computer, or driving?
Yes
No
If yes, please describe _______________________________________________________________________________
7. Do you perform any repetitive movement in your work, sports, or hobby? Yes
No
If yes, please describe _______________________________________________________________________________
8. Do you experience stress in your work, family, or other aspect of your life? Yes
No
If yes, how do you think it has affected your health? __________________________________________________
muscle tension ( ) anxiety ( )
insomnia ( )
irritability ( ) other: ___________________________________
9. Is there a particular area of the body where you are experiencing tension, stiffness, pain or other
discomfort?
Yes
No
If yes, please identify: ________________________________________________________________________________
10. Do you have any particular goals in mind for this massage session?
Yes
No
If yes, please explain: ________________________________________________________________________________
Circle any
specific
areas you
would like
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