Massage Therapy Intake Form printable pdf download

Massage Therapy Intake Form

General Information

Name: ________________________________________

Age:________

Birthday:_____/_____/_____

Address:_____________________________________

City:______________________

State:______

Zip:_________

Phone:__________________________

Email:________________________________

Marital Status:

Emergency Contact:____________________________

Relationship:________________

Phone: __________________

Employer:___________________________

Occupation:___________________________

Phone:__________________

Have you ever experienced a professional massage or bodywork session?

No Yes

How recently? ________________

How did you hear about us? ___________________________

Medical Information

Yes No

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Do you frequently suffer from stress?

Do you have diabetes?

☐

Do you experience frequent headaches?

Do you suffer from arthritis?

☐

Are you wearing contact lenses?

Do you have high blood pressure?

☐

Are you wearing dentures?

Do you suffer from epilepsy or seizures?

☐

Are you pregnant? Number of births:______

Do you have vericose veins?

☐

Do you suffer from joint swelling?

Do you have osteoperosis?

☐

Do you bruise easily?

Do you have cardiac or circulatory problems?

☐

Have you broken any bones in the past two years?

Have you ever had surgery?

☐

Do you suffer from back pain?

Do you have any contagious diseases?

☐

Have you been in an accident or suffered any injuries in the

Do you have numbness or stabbing pains anywhere?

past two years?

Where? ______________________________________

☐

Do you have tension or soreness in a specific area?

Where? ____________________________________

Please list any known allergies: __________________________________________________________________________________________

Please explain any other medical conditions: _______________________________________________________________________________

Please explain any medications you are currently taking (medication/frequency/for what): ___________________________________________

____________________________________________________________________________________________________________________

If you answered “yes” to any of the previous questions, please explain as clearly as possible: _________________________________________

____________________________________________________________________________________________________________________

Please take a moment to carefully read the following information and sign where indicated. If you have a specific medical condition or symptoms,

massage/bodywork may be contraindicated; a referral from your primary care provider may be required prior to services being provided.

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 session, I will 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 of which I am aware. I understand that massage/bodywork practitioners are not qualified to perform

spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session should be construed as

such. Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and

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 of the scheduled appointment.

Client Signature: ____________________________________

Date: ____________________________