Massage Therapy Client Intake Form printable pdf download

Massage Ther apy Client Intake For m

ETMC Olympic Center Massage Therapy

700 Olympic Plaza Tower

Tyler, TX 75701

Name: ___________________________________________________ Date ____________________

Address: _________________________________________________ Phone #:________________

Age: _______ Date of birth: _____________________________ Gender:  Male  Female

Occupation: ______________________________________ Physician: ________________________

Emergency contact: _______________________________________ Phone: ___________________

Are you under the age of 17? If yes, must have written consent of parent or guardian to receive

massage.

Our massage tables have a 325-pound weight limit. Please inform your therapist if your

weight exceeds this limit

Please check below all that apply:

 Allergies

 Epilepsy or seizures

 Contagious skin condition

 Back or neck problems

 Bruise easily

 Bone or joint injuries

 Varicose veins

 Current fever

 Migraines

 Smoke

 Heart condition

 Cancer

 High blood pressure

 Recent surgery

 Diabetes

 Current personal or job related stress

 Arthritis

 Currently pregnant?

 Back pain

Due date:_______________

Please explain any checked above: ______________________________________________________

______________________________________________________________________________________

If you have any other medical conditions your therapist should be made aware of please list:

_______________________________________________________________________________________

Current Medications:

_________________________________________________________________________________

Type of massage you are requesting (Please circle one below):

 Swedish/Relaxation  Deep Tissue  Trigger Point  Pregnancy Massage

 Hot Stone

Areas of pain/tension: _______________________________________________________________

Areas to be avoided: ________________________________________________________________

Massage Therapy Client Intake Form

Related Articles

Related forms

Related Categories