Massage Therapy Intake Form
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2Massage Therapy Intake Form
General Information
Name ________________________________________________
Date ______________________________________________
Address ______________________________________________
Home Phone (___________)___________________________
City _______________________ State _____ ZIP ___________
Work Phone (___________)____________________________
Email ________________________________________________
Occupation _________________________________________
Birthdate _____________________________________________
Referred by: ________________________________________
Emergency Contact _____________________________________
Phone (___________)_________________________________
Reason for visit:
Problem area(s) to be focused on (if any):
Relaxation (Swedish) Massage
Head, Neck & Shoulders
Upper Back
Therapeutic / Deep Tissue Massage
Lower Back
Arms/Hands
Neuromuscular Therapy
Legs/Feet
Other: _____________________________
Is this your first massage?
Yes
No
Any areas that you prefer not to be massaged: _____________________________
Health History
How would you rate your state of health?
Are you currently under the care of a physician?
Excellent
Good
Yes
No
Fair
Poor
If yes, for what reason? _______________________________________________
__________________________________________________________________
Medications/Reason
Allergies
Accidents/Surgeries
Include Date(s) for Each
_________________________________
__________________________
___________________________________________
_________________________________
__________________________
___________________________________________
_________________________________
__________________________
___________________________________________
Are you currently taking ANY medications
Are there any other current or previous health conditions that may be
(including pain medications, narcotics, anti-
affecting your health or functioning? Yes
No
inflammatories, muscle relaxants, or cortico-
If yes, please explain: ________________________________________________
steroids)? Yes
No
__________________________________________________________________
Anything else we should know in order to make your experience with us a positive one? ______________________________________
_____________________________________________________________________________________________________________
IMPORTANT – Please indicate if you have now, or ever have had, any of the following conditions, as standard massage techniques
may not be appropriate (use C for a current condition, P for a past condition):
____ High Blood Pressure
____ Osteoporosis
____ Pregnancy
____ Stroke
____ Swelling / Edema
____ Diabetes
____ Cancer ________________
____ Kidney Disease
____ Recent Injury
____ Chronic Pain Treatment
____ HIV / AIDS / Hepatitis/Infectious Disease
____ Fever / Acute Infection
____ Undiagnosed Acute Pain
____ Disease of the Heart or Blood Vessels
Please read and sign below: I understand that the massage therapist does not diagnose, prescribe, or treat any specific conditions. I understand
that massage therapy is not a substitute for medical examination, diagnosis, and treatment, and it is recommended that I see my physician for any
ailment I may have. I consent to receive bodywork from Carrie Bezusko, Licensed Massage Therapist, and will inform her at each visit of any
changes in my health.
Signature: ___________________________________________________________________ Date: ________________________________
PLEASE TURN THIS PAGE OVER, READ THE INFORMATION, AND SIGN & DATE WHERE INDICATED.
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