Intake Form

Massage Intake Form

Fields marked with * are required.
Basic Information
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail
Daytime Phone

Area CodePhone Number
Home Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Birth Date

MonthDayYear
Marital Status
Occupation
Referred By
Insurance?
Insurance Name
Policy Number
Emergency Contact Name

First NameLast Name
Emergency Contact Phone #

Area CodePhone Number
Physician Name

First NameLast Name
Physician Phone #

Area CodePhone Number
Massage Information
First Professional Massage?
How frequently do you have massage?
Medical Information
List accidents/injuries, hospitalizations, and surgeries: when they occured and treatment received
Any lingering effects from the above or do you feel you have recovered?
Chronic, ongoing pain?
Please describe any care or treatment you receive for chronic, ongoing pain
Do activities affect the pain?
If yes, please describe
Are you currently being treated medically or taking prescribed drugs?
If yes, please describe
Please list all over-the-counter drugs, supplements, and/or herbs taken and why
History

helps determine treatment options
Musculoskeletal
Gout in
Number of hours/day on computer
Other Musculoskeletal condition(s)
Respiratory
Other Respiratory condition(s)
Digestive
Circulatory
Describe Heart Problems
Other Circulatory Condition(s)
Skin
Other Skin Conditions
Nervous System
Other Nervous System condition(s)
Other
Describe Surgery
Other Conditions
Exercise
Times/day-week you exercise
Exercise Activities
Additional Information
Additional Information
Accuracy/Agreement
The above information is accurate. I understand that Massage Therapists do not diagnose disease or prescribe drugs and that they are not a substitute for medical care. I agree to alert my practitioner of any physical/emotional changes as they occur. I also understand that a missed appointment might incur charges that I must pay.
Typing my name below is the electronic version of my signature
Signature
Date
Should be Empty:

Massage Intake Form

Basic Information

Massage Information

Medical Information

History

Exercise

Additional Information

Accuracy/Agreement

Typing my name below is the electronic version of my signature