Massage Intake Form

Massage Therapy Intake Form

Please complete and submit this form no later than 24 hours before your massage appointment. If you have any questions call/text us at (973) 975-9625.
Name *

First Name Last Name
Date *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Date of Birth *
Occupation *
Phone Number *
Please enter a valid phone number.
Email *
example@example.com
Emergency Contact Name *
Emergency Contact Number *
Please enter a valid phone number.
The following information will be used to help plan safe and effective massage sessions. Please answer the questions to the best of your knowledge.
Have you had a professional massage before? If yes, how often? *
Do you have any allergies to oils, lotions, or ointments? If yes, please explain. *
Do you have sensitive skin? *
Do you have any particular goals in mind for this massage session? *
Please list specific areas you would like me to concentrate on during the session (if any): *
What kind of pressure do you like? (Light, Medium, Firm) *
During a typical massage session I work on the following areas: scalp, pectorals, back, neck, shoulders, arms, hands, glutes, legs and feet. Are there any areas you DON'T want worked on? *
Please indicate if any of the following apply: *

Joint Disorder Osteoporosis Cancer Back/Neck Problems Carpal Tunnel Syndrome Blood Clots Rheumatoid Arthritis Epilepsy Diabetes Fibromyalgia Tennis/Golf Elbow Osteoarthritis/Tendonitis Headaches/Migraines Depression/Anxiety TMJ Decreased Sensation Numbness/Tingling Pregnancy Contagious Skin Condition Recent accident or injury Artificial Joint Swollen Glands High or Low Blood Pressure Open Sores or Wounds Recent Fracture Strains/Sprains Allergies/Sensitivities Circulatory Disorder Bruises Easily Recent Surgery Heart Condition Varicose Veins None of the above Other
Please explain if you have any of the above, otherwise write "N/A" *
Are you currently under medical supervision? *
Are you currently taking any medications? If so, what are they for? *
Is there anything else about your health history that you think would be useful for me to know to plan a safe and effective massage session for you? *
Draping will be used during the session – only the area being worked on will be uncovered. Clients under the age of 18 must be accompanied by a parent or legal guardian during the entire session. Informed written consent must be provided by parent or legal guardian for any client under the age of 18.
I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so.
Signature *

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Massage Therapy Intake Form