Client Intake

MASSAGE THERAPY

Client Intake Form
Name
Date of Birth

MonthDayYear
Date
Occupation
Age
Address
City
State
Zip
Phone
Format: (000) 000-0000.
Email
example@example.com
Emergency Contact
Emergency Contact Phone
Format: (000) 000-0000.
Would you like to be added to our email list for news and exclusive offers?

YesNo
Medical History
Do you have or have you had any of the following conditions? If yes, please select them:

Arthritis / joint disorderArtificial jointAtherosclerosisBack/neck problemsBlood disorderCancerCarpal tunnel syndromeCirculatory disorderContagious skin conditionDecreased sensationDeep vein thrombosisDiabetesEasy bruisingEczemaEpilepsyFever blistersFibromyalgiaHeadaches/migrainesHeart conditionHigh/low blood pressureImmune disordersKeloid scarringOpen sores or woundsOsteoporosisPhlebitisPregnantRecent accident/injuryRecent fractureSeborrheaSeizure disorderSkin disease/lesionsSprains/strainsSwollen glandsTennis elbowTMJVaricose veins
Any other illness/condition?
Any recent surgery, including plastic surgery?
Have you had a professional massage before?

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

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

YesNo
Do you have sensitive skin?

YesNo
Are there any areas (feet, face, abdomen) you do not want massaged?
What type of massage are you seeking?

RelaxationTherapeutic/deep tissue
What pressure do you prefer?

LightMediumDeep
Mark any specific areas you would like your therapist to concentrate on:
By signing below, you agree to the following: 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 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.
Client Name printed
Client Name signature
Date

MonthDayYear
Date
Should be Empty:

MASSAGE THERAPY