Massage Therapy Client Health Intake Form
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1
2Patient Information
Name: _________________________________________
Address: __________________________________ City: ____________ State: ____ Zip: ________
Home Phone: __________________ Work/Cell Phone: __________________
E-mail:_______________________________________
Occupation: ________________________________ Date of Birth: ___________
Emergency Contact Person: _________________________ Phone: _________________
Are you currently under a physicians care for an acute or chronic illness? Y __ N __
If yes please explain: _____________________________________________________________
If yes, who is your health care provider: ______________________________________________
Are you currently taking any prescribed medication or dietary supplements? Y __ N __
If yes please explain: _____________________________________________________________
Have you received a massage before? Y__ N__ If yes, when: ___________________
How did you hear about me? _____________________________________________________________
What are your goals for this session: _______________________________________________________
Please list areas of tension, stress and/or pain you wish to be addressed: ___________________________
_____________________________________________________________________________________
Health Information
Please mark an (X) by all current conditions and (P) for all past conditions
__ Abdominal /digestive
__ Depression
__ Pregnancy
problems
__ Diabetes
__ Rash/fungus
__ Allergies
__ Fatigue
__ Sinus problems
__ Anxiety
__ Headaches, migraine
__ Sleep difficulties
__ Arthritis/tendonitis
__ Hearing problems
__ Spinal disorders
__ Asthma or lung cond.
__ Hernia
__ Sprain/strain
__ Athletes foot
__ High blood pressure
__ Tension/stress
__ Blood clots
__ Jaw pain/TMJ pain
__ Vision problems
__ Chronic pain
__ Low blood pressure
__Varicose veins
__ Circulatory/heart
__ Muscle/bone injuries
__ Other
problems
__ Muscle/joint pain
________________
__ Constipation/diarrhea
__ Numbness/tingling
Elaborate on noted areas above: ___________________________________________________________
_____________________________________________________________________________________
Please list any recent injuries or surgeries within the past 5 years: ________________________________
_____________________________________________________________________________________
Please list your stress-reduction activities, hobbies, exercise and/or sport participation: _______________
_____________________________________________________________________________________
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