New or Returning Clients

New or Returning Clients

Massage Intake Form
Personal Information
Name
Phone (day)
DOB
Occupation
Email
example@example.com
Emergency Contact
Relationship
Phone
How did you hear about us?
Medical Information
Are you taking any medications? *

Yes No
if yes, please list name and use:
Are you currently Pregnant? *

Yes No
If yes, how far along?
Any high risk factors?
Do you suffer from chronic pain? *

Yes No
if yes, please explain
What makes it better OR worse?
Have you had any orthopedic injuries? *

yes no
If yes, please list:
Please indicate any of the following that apply to you.

Cancer Fibromyalgia Headaches/Migraines Stroke Arthritis Heart Attack Diabetes Kidney Dysfunction Joint Replacement(s) Blood Clots High/Low Blood Pressure Numbness Neuropathy Sprains or Strains
Explain any conditions you have marked above:
Massage Information
Have you had a professional massage before? *

yes no
What type of massage are you seeking?

Relaxation Therapeutic/Deep Tissue
Other
What pressure do you prefer?

Light Medium Deep
Do you have any allergies or sensitivities? *

yes no
Are there any areas (feet, face, abdomen, etc) you do not want massaged? *

yes no
Please explain
What are your goals for this treatment session? *
Please list areas of discomfort (use image below to help identify)
By signing below, you agree to the following;

I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time.
Date *

Month Day Year
Date
Client Signature *

Clear
Should be Empty:

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New or Returning Clients

Personal Information

Medical Information

Massage Information