Therapeutic Massage Client Intake Form printable pdf download

Therapeutic Massage Client Intake Form

The information request below assists us in treating you safely. Feel free to ask any question about the information being requested.

Please note that all information provided below will be kept confidentially unless allowed or required by law. Your written permission

will be required to release any information.

Personal Information

Name:_________________________________________Phone #:__________________________________

Address:_______________________________________City, Zip:__________________________________

Email (optional):________________________________ Occupation:_________________Date of Birth:_________________

Emergency Contact:______________________________Phone:____________________________

Physician:______________________________________Phone:____________________________

Massage Information

Medical History

Do you suffer from chronic or persistent pain/discomfort?

Have you ever had a professional massage before? Yes

_______________________________________________________________

If yes, how often do you receive massage therapy?_______

If so, for how long?________________________________________________

Specify:

light pressure

medium pressure

deep tissue

Do you know what caused it or when the symptoms seem to get better or worse?

________________________________________________________________

What Type of massage are you seeking today?

Do you see a Chiropractor? Yes

Relaxation

Deep Tissue/Therapeutic

Pregnancy

if so, how often?___________________________________________________

Bowen

Are you currently under medical care? Yes

Are you sensitive to fragrances or perfumes? Yes

Are you currently taking any prescription medication? Yes

Do you have sensitive skin? Yes

if so, for what?___________________________________________________

Do you have contact lenses? Yes

________________________________________________________________

Do you exercises regularly? Yes

if so, what type(s)?___________________________

Please indicate any conditions that you have had or currently have:

is there a family history of any of the above?

What are your common areas of pain or tension?

headaches, migraines

Varicose Veins

____________________________________________________

allergies, sensitivity

pregnancy

____________________________________________________

cancer

blood clots

____________________________________________________

TMJ problems

paralysis

Circle any specific areas you would like the massage therapist

abnormal skin conditions

fibromyalgia

to concentrate on during the session:

joint replacement / surgery

numbness

high/ low blood pressure

sprains, strains

heart/circulation problems

recent injuries

major accidents

epilepsy

diabetes

arthritis

dizziness

inflammation

cuts, Burns, Bruises

depression

lack of or reduced feeling / sensation____________________________

Explain any conditions that you have marked above:

________________________________________________________________

________________________________________________

__________________

_________________________________________________

I understand that I have the right to ask questions about my treatment. If at any time I feel uncomfortable, I understand

that I can ask the therapist to alter or stop treatment, or to clarify the reason for the particular technique being used. I

understand that massage s designed for the purpose of relaxation and relief from tension, muscle spasms or poor

circulation. The massage therapist cannot diagnose medical issues/diseases/disorders. I understand that I will be charged a

cancellation fee if I do not give 4 hours notice of a change or cancellation of appointments. With this knowledge, I give

my consent to proceed with the treatment as described by the therapist.

Client Signature____________________________________________________________Date_____________________

Therapeutic Massage Client Intake Form

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