Client Intake Form For Massage Therapy printable pdf download

Client Intake Form For Massage Therapy

Name_________________________________ Date of Birth_______________

Address__________________________________________________________

City______________________ State___________ Zip Code________________

Home Phone(___)______________ Work Phone(___)_____________________

Cell Phone(___)________________E-mail Address_______________________

Referred By________________________ Phone(___)_____________________

Emergency Contact__________________ Phone(___)_____________________

Do you currently have or have had in the past the following conditions in any form,

please check the appropriate box, please explain below.

Stress

Back Pain

Sensitivity or allergy to heat

Epilepsy or seizures

Diabetes

Open wounds, lesions, rashes, or infections

Headaches/migraines

Skin Problems/irritations

Currently pregnant or lactating

Broken bones in the past 2 years

Arthritis

Have you recently had surgery

High blood pressure

Varicose veins

Allergies

Cancer

Tension/soreness in a specific area. If so, where?___________________________

Numbness or stabbing pains anywhere. If so, where?_________________________

Any additional information that I should be aware of?

______________________________________________________________________

Are you taking any medications that I should know about?

______________________________________________________________________

Is this your first massage experience?______________ If you answered no, when was

your last massage?________________________________________

Please explain your reason for having a massage:______________________________

Please take a moment to read the following information

I understand that the massage/bodywork I receive is provided for the basic purpose of relaxation

and relief of muscular tension. If I experience any pain or discomfort during this and future

sessions, I well immediately inform the practitioner so that the pressure and/or strokes may be

adjusted to my level of comfort. I further understand that massage/bodywork should not be

construed as a substitute for medical examination, diagnosis, or treatment and that I should see a

physician, chiropractor or other qualified medical specialist for any mental or physical ailment that

I am aware of. Because massage/bodywork should not be performed under certain medical

conditions, I affirm that I have stated all my known medical conditions, and have answered all

questions honestly. I agree to keep the practitioner updated as to any changes in my medical

profile and understand that there shall be no liability on the practitioner’s part should I fail to do so.

I also understand that any illicit or sexually suggestive remarks or advances made by me will

result in immediate termination of the session, and I will be liable for payment in full of the

scheduled appointment. I also understand that if I cancel or do not show to any massage

appointment without at least 24 hours notice, I am responsible for payment in full. I will be

charged $70.00 (Cost of one-hour session) or $40.00 (Cost of half hour session) and it will be due

in full within three (3) days of missed appointment.

Name (printed) ____________________________

Date_____________________

Signature_________________________________

Client Intake Form For Massage Therapy

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