Client Intake Form Template printable pdf download

Client Intake Form

Name:_________________________________________________________ Date of Birth:____/____/_______

Mailing Address:______________________________________________________________________________

City, State, Zip: ______________________________________________________________________________

Home Phone: (_______)________-_________________ Cell Phone: (_______)________-__________________

E-mail Address:_______________________________________________________________________________

Occupation: ____________________________________ Work Phone: (_______)_______-__________________

Referred By: __________________________________________________________________________________

What is the best way to contact you? □ Home □ Cell □ Work □ E-mail

Emergency Contact: _________________________________________ Relationship:______________________

Phone: (______)_______-___________________

Alternate Phone: (______)_______-___________________

Goal For Today’s Session: □ Relaxation □ Bodywork

General & Medical Information

Have you ever had a professional massage? Yes No

Are you pregnant? Yes No If yes what trimester?___________

Mark the area(s) of pain/tension below:

Are you currently suffering from a cold or fever? Yes No

Do you have tension or soreness in a specific area? Yes No

Explain:______________________________________________

Are you experiencing any numbness or stabbing pain? Yes No

Explain:______________________________________________

Are you sensitive to pressure or touch in any areas? Yes No

Explain:______________________________________________

Do you exercise regularly?

Yes No How often ___________

What type(s)__________________________________________

How many glasses of water do you drink per day? __________

How would you classify your level of stress? Low Med High

Do you have now or have you ever had:

Frequent headaches

Yes No

Asthma

Yes No

Varicose veins

Yes No

Skin disorders

Yes No

Surgery

Yes No

Allergies

Yes No

Cardiac or circulation problems

Yes No

Cancer

Yes No

Diabetes

Yes No

Broken bones

Yes No

High or low blood pressure

Yes No

Rash, broken skin, or bruises

Yes No

If the answer to any of the above questions is yes please explain below: _______________________________________________

_____________________________________________________________________________________________________________

Are you currently under the care of a physician? If yes please explain:_________________________________________________

_____________________________________________________________________________________________________________

Are you taking any medication? Yes No

If yes please list and explain: ______________________________________________

_____________________________________________________________________________________________________________

Do you have any other medical conditions that I should be aware of? __________________________________________________

_____________________________________________________________________________________________________________

Please take a moment to carefully read the information you have provided and sign where indicated.

The above information is accurate to the best of my knowledge. I agree to update the massage therapist in regard to any

changes in my heath and understand that there shall be no liability on the therapists part should I forget to do so.

Client Signature _______________________________________________________________

Date ________________________

Client Intake Form Template

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