Client Intake Form printable pdf download

Client Intake Form

Date: ___________________

NAME: ____________________________________________________________BIRTHDAY ____/_____/______

ADDRESS______________________________________CITY/STATE/ZIP________________________________

HOME PHONE#_________________________________CELL PHONE#________________________________

EMAIL: _________________________________________OCCUPATION:________________________________

EMERGENCY CONTACT:____________________________________PHONE#__________________________

THE FOLLOWING INFORMATION WILL BE USED TO HELP PLAN SAFE & EFFECTIVE MASSAGE SESSIONS EACH TIME YOU VISIT US.

*** Your contact and personal information is for Massage Green use only and will not be shared with any person or entity outside of

Massage Green.

IT IS IMPORTANT THAT YOU ANSWER ALL QUESTIONS TO THE BEST OF YOUR KNOWLEDGE AND HONESTY. THANK YOU.

Have you had professional massages before?

If yes, how often are your massages? ________________________

Do you have difficulty lying on your front, back or sides? Y

N Explain: ______________________________________________

Do you have allergies to any oils, lotions or ointments? Y

Explain: ________________________________________________

Do you have sensitive skin?

Are you wearing contacts?

Hearing Aids?

Dentures?

Do you sit for long hours at a workstation such as a computer or driving? Y

Describe: _____________________________

Do you perform repetitive movement in your work, sports or hobby? Y

N Describe: _________________________________

Do you have stress in your work, family or other aspect of your life? Y

How do you feel this has affected your health?

WITH: Muscle Tension ( ) Anxiety ( ) Insomnia ( ) Irritability ( )

Other_______________________________________

Is there a particular area of the body where you are experiencing

TENSION?

STIFFNESS?

PAIN?

OTHER?

Identify with detail: _____________________________________________________________________________________________

Do you have any particular goals in mind for this massage session?

If yes, please describe: ____________________ _____________________________________________________________________

What areas of your body would you like the massage therapist to concentrate on during this session:

Client Intake Form