Massage Therapy Client Intake

Massage Therapy Intake Form
Full Name*

First NameMiddle NameLast Name
Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date

MonthDayYear
Phone *
E-mail*
Emergency Contact*
Phone Number*
Occupation
Medications
Allergies or sensitivie to Oils or essential oils?
Please list any medical conditions.*
Have you ever been in an accident (automobile, work, falls, etc.) ? Include approximate date of incident and any therapies or procedures relating to injuries.*
What is your main daily activity?
Please check any that apply:
Head

TemplesForeheadTop of headIn the eyesBase of skullDizzinessLight-headednessPain in earsRinging in earsJawOther
Shoulders

Left shoulder painRight should painDiagnosed bursitisDiagnosed ArthritisCan't raise arm above shoulder levelOther
Neck

StiffnessPain when turning headDiagnosed bone spursDiagnosed disc herniation or compressionOther
Arms & Hands

Pain in right arm/handPain in left arm/handSwollen joints in fingersDiagnosed arthritisOther
Mid-Back

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

Low 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 coughingDiagnosed disc herniation/compressionOther
Hip

Pain in buttocksPain 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 crampsFeet feel coldFoot CrampsPain in RIGHT kneePain in LEFT kneeDiagnosed ArthritisOther
Mental and Emotional / Optional

Brain Fog - confusion or spaceyFeeling of disconnection - isolationLow mood / DepressionExcessive brain chatterHard time letting goTransition strugglesGrief, current or unresolved - HeartCompulsiveOverly fearfulInappropriate guilt/shame - HeartRigidity/unmoving/stubbornGeneral StressTrust issuesPoor self image/esteemRelationship / communication strugglesLack of purpose, meaning or directionOverly critical/judgemental of others or selfEasy to anger
Main reason(s) for massage today?*
Ie; right hip, neck, scalp massage, left wrist
• If possible, please come showered without fragranced lotions or bodycare products.

• Please reschedule your session if you are more than 15 minutes late.

• If you have long hair, please bring a hair tie or clip.

Client Agreement: I understand that although massage therapy can be therapeutic, relaxing and reduce muscular tension, it is not a substitute for medical examination, diagnosis and/or treatment. I attest I disclosed all bodily conditions accurately or to the best of my knowledge. I undersand that if at any time I feel pain or discomfort during the session, I will immediately inform my therapist so she can adjust technique and or pressure. I will update Body Mind Mana of any changes in my health status.
Signature*

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