MASSAGE INTAKE FORM

Client Intake Form - Therapeutic Massage
Name
Email
example@example.com
Phone (cell/day)
Format: (000) 000-0000.
DOB
Age
Address

Address

Street Address Line 2

City/State/ZipState / Province

Postal / Zip Code
Emergency Contact Name
Phone
Format: (000) 000-0000.
Relationship
Occupation
Referred by
Health Information
Are you taking any medications?
If yes, please list
Any allergies? (oils, lotions, nuts, fruits, skin, etc
If yes,
Are you pregnant?
Are you pregnant?
If yes, how many months
Due date

MonthDayYear
Date
Are you you currently under medical supervision or receiving other medical interventions?
If yes, please describe
Do you have any of the conditions? Please check all that apply:
Areas of broken skin?
If yes, where?
History of joint replacement surgery?
Which joint(s) ?
Recent injuries or medical procedures in the past 2 years?
If yes, please describe:
How recently?
Please describe any other injuries or health conditions:
Massage Information
Have you had a professional massage before?
How recently?
Reason for seeking a massage today:
Please specify areas of discomfort:
How much pressure do you prefer
By signing below, / acknowledge that / am aware of the benefits and risks of massage therapy and that / have completed this form to the best of my knowledge. / also agree to inform my massage therapist of any health or medical changes.
Client Signature
Date

MonthDayYear
Date
Therapist Signature
Date

MonthDayYear
Date
Should be Empty:

Health Information