Client Intake Form printable pdf download

Heart of Life Massage, LLC

Client Intake Form

Name _________________________ Phone(day) ___________________ Cell _________________

Address _____________________________________ City/State/Zip _________________________

Email ___________________________________________

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 ever had a professional massage before? Yes No

If yes, how often? _____________________________________________________________

Do you have difficulty lying on your front, side or back? Yes No

If yes, please explain __________________________________________________________

Do you have any allergies to oils, lotions, ointments, fruits or nuts? Yes No

If yes, please explain __________________________________________________________

Do you have sensitive skin? Yes No

Are you wearing [ ] contact lenses [ ] dentures [ ] hearing aid [ ] prosthetics

Do you sit for long hours at a workstation, computer or driving? Yes No

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 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 your body where you are experiencing tension, stiffness, pain or discomfort?

Yes No If yes, please identify __________________________________________________

Do you have any particular goals in mind for this massage session? Yes No

If yes, please explain __________________________________________________________

Medical History

Do you currently or have you ever had any of the following? (please check)

Client Intake Form