Massage Client Intake Form

Name*

First NameLast Name

Phone*

Address*

Address

Street Address Line 2

City/State/Zip

email*

example@example.com

Date of Birth*

Date

Occupation

The following information will be used to help plan safe and effective massage sessions. Please answer the questions to the best of your knowledge.

Date of Initial Visit

Date

Have you had a professional massage?

YesNo

If yes, how often do you receive massage therapy?

2. Do you have any difficulty lying on your front, back, or side?

YesNo

If yes, please explain

3. Do you have any allergies to oils, lotions or ointments?

YesNo

If yes, please explain

4. Do you have sensitive skin?

YesNo

If yes, please explain

5. Do you sit for long hours at a workstation, computer or driving?

YesNo

If yes, please explain

6. Do you perform any receptive movements in your work, sports or hobby?

YesNo

If yes, please describe

7. Is there a particular area of the body where you experience tension, stiffness pain or discomfort?

YesNo

If yes, please describe

8. Do you have any particular goals in mind for this massage session?

YesNo

If yes, please explain

In order to plan a massage session that is safe and effective, I need some general information about your medical history.

9. Are you currently under medical care?

YesNo

If yes, please explain

10. Do you see a chiropractor?

YesNo

If yes, how often?

11. Are you taking any medication?

YesNo

If yes, please list.

12. Please check any condition listed below that applies to you:

13. Is there anything else about your health history that you think would be useful for your massage practitioner 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 17 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 17.

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, | 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 of client

Date

Signature of Massage Therapist

Date