Massage Therapy Intake Form

MASSAGE THERAPY INTAKE FORM
Name

First NameLast Name
Sex

MaleFemale
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Daytime Phone
Please enter a valid phone number.
Evening Phone
Please enter a valid phone number.
Email
example@example.com
Date of Birth

MonthDayYear
Date
Occupation
Preferred Appointment Day and Time
Primary Health Care Provider
Provider's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Provider's Phone
Extension
Persomission to consult with Primary Provider?

YesNo
If yes, please initial
Emergency Contact
Name

First NameLast Name
Relationship
Telephone
The following information will be used to plan safe and effective massage sessions. Please answer to the best of your knowledge.
1. Have you had a professional massage before?

YesNo
If yes, how often do you receive massage therapy?
2. Do you have 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
5. Are you currently wearing:

Contact lensesDenturesA hearing aid
6. Do you sit for long hour at a workstation, computer, or driving?

YesNo
If yes, please describe.
7. Do you perform any repetitive movement in your work, sports or hobbies?

YesNo
If yes, please describe.
8. Do you experience stress in your work, family or other aspects of your life?

YesNo
If yes, how do you think it has affected your health?

Muscle tensionAnxietyInsomniaIrritabilityOther
9. Is there a particular area of the body where you are experiencing tension, stiffness, pain or other discomfort?

YesNo
If yes, please describe.
10. Do you have any particular goals in mind for this massage session?

YesNo
If yes, please explain
Please list any specific areas you would like the massage therapist to concentrate on during this session:
11. Are you currently under medical supervision?

YesNo
If yes, please explain.
12. Do you see a chiropracter?

YesNo
If yes, how often?
13. Are you currently taking any medications?

YesNo
If yes, please list.
14. Please check any condition listed below that applies to you:*

Headaches/MigrainesJoint disorder/rheumatoid arthritis/ osteoarthritis/tendonitisStrains/sprainsArtificial jointRecent surgeryRecent fractureRecent accident or injuryOsteoporosisVaricose veinsCirculatory DisorderPhlebitisDeep vein thrombosis/blood clotsDecreased sensationBack/neck problemsTennis elbowEpilepsyHeart ConditionAllergies/sensitivityHigh or low blood pressureCancerDiabetesFibromyalgiaContagious skin conditionOpen sores or woundsEasy bruisingCurrent feverSwollen glandsAtherosclerosisTMJCarpel tunnel syndromePregnantOther
If pregnant, how many months along?
Please explain any condition that you have marked above
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.

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, diagnosis, 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/Legal Guardian

Clear
Date

MonthDayYear
Date
Should be Empty:

MASSAGE THERAPY INTAKE FORM

Emergency Contact