Massage Client Intake Form printable pdf download

Massage Client Intake Form

MASSAGE CLIENT INTAKE FORM

Personal Data

Today’s Date: ________________________

First Name: _________________________ Last Name: _________________________

Date of Birth: _______________________

Whom may we thank for your referral? ________________________________________

Health Data

Reason for initial visit: _____________________________________________________

Serious illnesses, injuries, or surgeries: ________________________________________

________________________________________________________________________

Medications: _____________________________________________________________

________________________________________________________________________

Name of Regular Doctor: ______________________________________

Emergency Contact: _________________________ Phone: ______________________

Please check all that apply:

_____ arthritis

_____ autoimmune disorder

_____ breathing problems

_____ bruise easily

_____ cancer

_____ carpal tunnel

_____ diabetes

_____ epilepsy

_____ heart problems

_____ high blood pressure

_____ migraines

_____ numbness sensations

_____ pregnant

_____ psychotherapy

_____ sciatica

_____ sinuses

_____ skin conditions

Please mark areas that cause the most

_____ stress

discomfort.

_____ TMJ

_____ varicose veins

_____ whip lash

Massage Client Intake Form