MASSAGE INTAKE FORM

Client Intake Form - Therapeutic Massage
Name
Email
[email protected]
Phone (cell/day)
DOB
Age
Address

Address

Street Address Line 2

City/State/ZipState / Province

Postal / Zip Code
Emergency Contact Name
Phone
Relationship
Occupation
Referred by
Health Information
Are you taking any medications?

YesNo
If yes, please list
Any allergies? (oils, lotions, nuts, fruits, skin, etc

YesNo
If yes,
Are you pregnant?
Are you pregnant?

YesNo
If yes, how many months
Due date

MonthDayYear
Date
Are you you currently under medical supervision or receiving other medical interventions?

YesNo
If yes, please describe
Do you have any of the conditions? Please check all that apply:

Areas of swellingAutoimmune DisorderBack & Neck ProblemsBleeding DisorderBlood clotsBruise easilyBrusitisCancerContagious conditionDecreased sensationDiabetesFibromyalgiaHeadachesHeart conditionHypertensionKidney diseaseMutliple ScierosisNeurological conditionNeuropathyOsteoarthritisOsteoporosisPhlebitisSciaticaSeizuresStrokeTendinitisTMJ DisorderVaricose veinsVertigo/dizziness
Areas of broken skin?

YesNo
If yes, where?
History of joint replacement surgery?

YesNo
Which joint(s) ?
Recent injuries or medical procedures in the past 2 years?

YesNo
If yes, please describe:
How recently?
Please describe any other injuries or health conditions:
Massage Information
Have you had a professional massage before?

YesNo
How recently?
Reason for seeking a massage today:
Please specify areas of discomfort:
How much pressure do you prefer

LightMediumFirm
By signing below, / acknowledge that / am aware of the benefits and risks of massage therapy and that / have completed this form to the best of my knowledge. / also agree to inform my massage therapist of any health or medical changes.
Client Signature

Clear
Date

MonthDayYear
Date
Therapist Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Health Information

Massage Information