Massage Therapy Client Intake

Client Intake Form

All information is held in 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.

Date *

Month Day Year

Full Name *

First Name Middle Initial Last Name Suffix

Pronoun (i.e. She/Her, He/Him, They/Them, Etc.)

Birth Date *

Month Day Year

Address *

Street Address

Street Address Line 2

City State

Zip Code

Phone Number *

E-mail *

Emergency Contact *

Phone Number *

Occupation

Medications

Allergies *

How did you find out about my services? *

History of Pathology

1. List area of discomfort, pain or impairment, if any. Please describe your experience in detail. If multiple areas are involved, there is space near the bottom of this form where you can get more specific.

2. Describe onset of condition or symptoms, if applicable. (When did you first notice it?)

3. Frequency of symptoms, if applicable.

Constant Off & On At Rest With Activity

4. At what time of day are symptoms worse?

Morning Afternoon Evening While Asleep All Day

5. Have you ever injured this area before? If so, please describe listing when and how it affected you, including treatments received.

6. Is there anything you do that creates, increases or decreases pain?

7. Rate of pain today on scale of 0-10

8. Have you ever been in an accident (automobile, work, falls, etc.)? If so, please describe when and how it affected you.

9. Have you ever had surgery? If so, please describe and list when you had it.

10. Do you manage any type of emotional distress or mental illness (such as depression, anxiety, PTSD, etc.)? If you're comfortable sharing, you may do so below.

11. Are you a survivor of any physical or sexual violence / unwanted physical contact?

12. What are the physical duties required of your occupation, hobbies, or other activities?

13. Please list exercise and stress reduction activities (including frequency).

14. In what position do you most often sleep?

Back Side Stomach A combination

15. Are you currently seeing any other healthcare professional? If so, please indicate which type and frequency with which you receive their services.

16. Have you ever received therapeutic massage for a specific issue or injury?

Was the massage treatment used effective?

17. What level of pressure do you generally prefer for your massages?

18. What are you hoping to get out of your massage session? *

If various symptoms or conditions are present in multiple areas, please indicate which areas of your body are affected and what your experience is like. Be sure to mention which side of the body is affected or if it's both, when applicable.

HEAD:

NECK:

SHOULDERS:

ARMS & HANDS:

BACK:

HIPS & BUTTOCKS:

LEGS & FEET:

Massage Policies:

* All clients' information is kept confidential and will be released only with a client's written consent.

• Please be on time and notify your therapist if you're going to be late to ensure there will be enough time for your session.

• 24 hour cancellation notice is required to avoid being charged half the regular fee - some exceptions do apply.

• A consultation will be provided prior to your session to discuss your symptoms/condition and identify personal preferences and treatment goals.

• Please turn off your cell phone for optimal relaxation during your session.

• You will be modestly draped the entire time and are encouraged to disrobe after the therapist has left the room only to a level you are comfortable with.

• Either the massage therapist or client may end the session at any time for any reason but may still be charged for a full session.

• Inappropriate behavior will not be tolerated and may be prosecuted to the full extent of the law.

Client Agreement:

I understand that licensed massage therapists do not diagnose illness, disease, any physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals, or perform joint mobilization.

I acknowledge that massage therapy is not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for that service.

It is my choice to receive therapeutic massage as a form of therapy.

I understand that treatment given is designed to address the care and prevention of myofascial pain and dysfunction.

I also undersand that at any time I feel pain or discomfort during the session, I will immediately inform my massage therapist so they can adjust.

I have shared all pertinent medical information, and will update the massage therapist of any changes in my health status.

I understand that my failure to do so may pose a threat to my health and physical well being and I hold harmless this massage therapist from any liability whatsoever arising from failure on my part.

By my electronic signature below, I agree to the massage policies and client agreement above.

Signature *

Sign by using a touch tablet/screen or left click and hold as you sign with your mouse. Clear