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

Format: (000) 000-0000.

E-mail

Emergency Contact

Phone Number

Format: (000) 000-0000.

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

Shoulders

Neck

Arms & Hands

Mid-Back

Low Back

Other

Hip

Legs and Feet

Mental and Emotional / Optional

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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