Client Intake Form printable pdf download

Client Intake Form

Personal Information:

Name: ____________________________ Phone (cell): ________________ Phone (home): _______________

Address: ___________________________________________________________________ Apt#: _________

City/State/Zip: _____________________________________________________________________________

Email: ______________________ Date of Birth: _____________ Occupation: __________________________

Emergency Contact: ___________________________________ Phone (cell): __________________________

General Information:

The following information will be used to help plan a safe and effective massage session.

Please answer the questions to the best of your knowledge.

Have you ever had a professional massage before? If yes, when: _____________________

Have you ever had surgery? If yes, please explain: ___________________________________

Have you ever had a serious accident? (Motor vehicle, Fall, etc)

If yes, please explain: ___________________________________________________________

Do you have tension or soreness in a speciﬁc area? __________________________________

What activities/positions/movements make this worse? ______________________________

Are there any areas of the body that you do not want to be worked on?

If yes, please list: ______________________________________________________________

What are your goals for the session(s)? ______________________________________

On the pictures below, please shade the areas that you would like the therapist to focus on.

Initial: ______

Client Intake Form