Massage Therapy Client Intake

Client Intake Form

All information is held strictest confidence. At no given point is information disclosed or shared without client’s written consent. You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose.
Full Name*

First NameMiddle NameLast Name
Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date

MonthDayYear
Phone Number*
This is my:*
E-mail*
Emergency Contact*
Phone Number*
Occupation
Medications
Allergies
History of Pathology
1. List Areas of Discomfort or Pain*
2. Describe Onset of Discomfort or Pain*
3. Frequency - please select the most accurate*

ConstantOff/OnAt RestWith ActivityOther
4. Have you ever been in an accident (automobile, work, falls, etc.) ?*
5. List all related treatments received for this injury.
6. Have you ever received therapeutic massage for a specific problem or injury?
7. Was the treatment used effective?
8. Is there anything that you do that creates, increases or decreases pain? *
9. Are you currently seeing any other healthcare professional (physical therapist/chiropractor)?
Please check any symptoms that apply to you and indicate right or left when applicable:
Head

TemplesForeheadTop of headIn the eyesEntire headBase of skullDizzinessFaintingLight-headednessPain in earsRinging in earsOther
Neck

StiffnessPain at neck shoulder junctionPain when turning headPain with side to side movementsNeck feels out of placeMuscle spasm in neckGliding/Grating sound with neck movementDiagnosed bone spursDiagnosed disc herniationOther
Shoulders

Pain in shoulderFrontBackSidePain deep in shoulder jointDiagnosed bursitisDiagnosed ArthritisCan't raise arm above shoulder levelCan't raise arm over headOther
Arms & Hands

Pain in upper armPain in forearmPain in wristPain in fingersSensation of pins & needles in armSensation of pins & needles in fingersFingers go to sleepHands coldSwollen joints in fingersSore joints in fingersDiagnosed arthritisLoss of grip strengthOther
Mid-Back

Mid-back painPain between shoulder bladesPain up/down backPain across mid backPain with breathingOther
Low Back

Low back painLow back pain is worse when workingLow back pain is worse when liftingLow back pain is worse when stoopingLow back pain is worse when standingLow back pain is worse when sittingLow back pain is worse when bendingLow back pain is worse when coughingPinched nerve in low backLow back feels out of placePain up/down low backPain across low backDiagnosed disc herniationOther
Hip

Pain in buttocksPain in buttocks when standingPain buttocks in buttocks when sittingPain on side of hipPain deep in hip jointPain on sit boneDiagnosed bursitisDiagnosed arthritisOther
Legs and Feet

Pain down RIGHT legPain down LEFT legPain down BOTH legsLeg crampsPin & Needles in RIGHT legPin & Needles in LEFT legNumbness in RIGHT legNumbness in LEFT legNumbness in RIGHT footNumbness in LEFT footNumbness in toesFeet feel coldCramps in RIGHT footCramps in LEFT footSwollen RIGHT ankleSwollen LEFT AnkleSwollen RIGHT footSwollen LEFT footPain in RIGHT FootPain in LEFT FootPain in RIGHT kneePain in LEFT kneeDiagnosed ArthritisOther
Signature*

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