Massage Therapy Client Intake Form Page 2
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4Intake Form
Circle the following conditions that apply to you, past and present. Please add your comments to clarify the
condition.
Musculo-Skeletal
Digestive
Skin
Headaches
Indigestion
Rashes
Joint stiffness/swelling
Constipation
Allergies
Spasms/cramps
Intestinal gas/bloating
Athlete’s foot
Broken/Fractured bones
Diarrhea
Acne
Strains/Sprains
Irritable bowel syndrome
Impetigo
Back, hip pain
Crohn’s Disease
Hemophelia
Shoulder, neck, arm, hand pain
Colitis
Leg, foot pain
Other:_____________
Other
Chest, ribs, abdominal pain
Problems walking
Loss of Appetite
Jaw pain/TMJ
Nervous System
Depression
Tendonitis
Difficulty concentrating
Bursitis
Numbness/tingling
Hearing Impaired
Arthritis
Fatigue
Visually Impaired
Osteoporosis
Sleep disorders
Diabetes
Scoliosis
Ulcers
Fibromyalgia
Other:________________
Paralysis
Post/Polio Syndrome
Herpes/shingles
Cancer
Circulator/Respiratory
Cerebral Palsy
Tuberculosis
Epilepsy
Other:________________
Dizziness
Chronic Fatigue Syndrome
Shortness of breath
Multiple Sclerosis
Fainting
Muscular Dystrophy
Cold feet or hands
Parkinson’s Disease
Cold sweats
Other:__________________
Stroke
Heart condition
Reproductive System
Allergies
Asthma
Pregnancy
High blood pressure
Low blood pressure
Other:_________________
I understand that a massage Therapist does not diagnose disease, illness, or prescribe any treatment or drugs,
nor do they provide spinal manipulation. I understand that draping will be used at all times and that breast
massage will not be administered on female clients. I understand that if I become uncomfortable for any
reason that I may ask the Therapist to end the massage session, and they will end the session. I understand
that the massage Therapist may end the session for any inappropriate behavior. I have stated all of the
conditions that I am aware of, and this information is true and accurate. I will inform the health care
provider of any changes in my status.
Client’s signature____________________________________________ Date______________________
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