Massage Therapy Client Intake

Massage Therapy 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 NameLast Name
Birth Date

DayMonthYear
Phone number:*
Address*

House No:

Street:

Town:

Postcode
E-mail*
example@example.com
Emergency Contact*
Phone number:*
History History
Please tick if you had, or are suffering from any of the following conditions:
Medication*

DiabetesEpilepsyCancerDepressionAsthmaM.S.High/ Low Blood pressureBack/Neck problemsEczema/psoriasisAllergiesHeartPMTMenopauseIrregular periodsPregnant or tryingFoot disordersNone aboveOther
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
I authorize this massage spa clinic/center to perform the treatment or necessary procedure for my child.

I authorize the use of lotion, oil, and ointments to my body.

I acknowledge that I have consulted a physician before undergoing this massage treatment. I understand that I should consult my doctor before the procedure.

I understand that this is an alternative treatment and if there are any medical concerns, I need to talk to my physician.

I acknowledge that this massage therapy has no sexual intent and touching the therapist is strictly prohibited.

I release this massage spa clinic/center for any responsibility in case of an accident, illness, or injury.

I acknowledge that all information I provided int his form is true and accurate.
Signature*

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