Massage Therapy Intake Form

Full Name (no initials)*

First NameLast Name

Gender*

MaleFemaleOther

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth*

Date

Phone Number*

Occupation*

This can help identify common problem areas

Health Fund (if claiming a rebate)*

Emergency Contact Details*

Name, phone number and relationship to you

Details of previous professional massage

e.g. type of massage, conditions treated, results of treatment

Referred by

e.g. friend's name, Google search, Facebook page

Reason for seeking massage*

e.g. neck/shoulder pain, low back pain, tight hamstrings, sports injury

Regular exercise / physical activity*

e.g. work/home activity, walking/cycling to work, gym, sports

Do you currently or frequently have any of the following?*

Low back painNeck painHeadachesNone

Are you currently experiencing any of the following?*

Please provide details if you selected any above

e.g. severity, location, type, any allergens

Are you now under medical / therapeutic treatment?*

YesNo

If so, for what condition(s)?

Describe conditions being treated

Illnesses, injuries or conditions you have now or in the past 3 years*

Please provide details if you selected any above

Describe illnesses, injuries or conditions and when you had them

Medications taken in the past week*

Please provide details if you selected any above

Name of medication and when taken

I have chosen to consult with and hereby give consent for massage therapy to be provided by Brendan Lo who I understand is a member of the Association of Massage Therapists Ltd (AMT). I have provided a detailed medical history. I do not expect the therapist to have foreseen any previous or pre-existing condition that I have not mentioned. I understand that massage may provide benefits for certain conditions but results are not guaranteed. These benefits may include relief of muscular tension, relaxation, reduction in the symptoms of stress-related conditions and provision of general wellbeing. I also understand that massage therapy may produce side effects such as muscle soreness, mild bruising, increased awareness of areas of pain and light-headedness amongst other possible temporary outcomes. I am aware that the therapist does not diagnose illnesses, prescribe medications nor physically manipulate the spine or its immediate articulations. The therapist understands that I have the right to question procedures used and to receive an explanation of any procedures that the therapist performs. I will tell the therapist about any discomfort I may experience during the therapy session and understand that the therapy will be adjusted accordingly.

Signature*

Date*

Date

Client Intake Form