MASSAGE THERAPY CLIENT INTAKE FORM
Massage Melts
Licensed Massage Therapist: Jevon Martin, LMT
Personal Information
Date:
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Full Name:
First Name
Last Name
Date of Birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age:
Phone:
Format: (000) 000-0000.
Email:
example@example.com
Emergency Contact:
Format: (000) 000-0000.
Health History
Primary reason for today's visit:
Have you received professional massage before?
Yes
No
Current Pain or Problem Areas
Neck, Shoulders, Upper Back, Mid Back, Lower Back, Hips, Glutes, Legs, Feet, Arms, Hands, Jaw (TMJ), Headaches, Other:
Pain Level (0-10):
Medical History
Check any that apply:
High/Low Blood Pressure
Diabetes
Heart Disease
Cancer
Arthritis
Fibromyalgia
Osteoporosis
Asthma
Blood Clots
Varicose Veins
Seizures
Migraines
Anxiety
Depression
Pregnancy
Recent Surgery
Recent Injury
None
Other conditions:
Medications & Allergies
Current medications:
Allergies:
Lifestyle
Back
Next
Occupation:
Stress Level (1-10):
Massage Preferences
Preferred Pressure:
Light
Medium
Firm
Deep Tissue
Areas to focus:
Areas to avoid:
Temperature Preference:
Warm
Cool
Music Preference:
Relaxing
Nature
Instrumental
None
Draping & Treatment Consent
Please indicate consent for treatment of: Neck, Shoulders, Arms & Hands, Upper Back, Lower Back, Glutes, Hips, Legs, Feet, Abdomen (if requested), Scalp/Face.
Client Consent
I understand massage therapy is for relaxation and wellness and is not a substitute for medical care. I may stop the session at any time, will communicate discomfort, proper draping will be maintained, inappropriate behavior ends the session immediately, and I will disclose health changes.
Client Signature:
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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