Client Intake & Consent Form

Client Intake & Consent Form

Complete your health details, preferences, and consent information before your massage appointment.
Client Information
Client full name

First NameMiddle NameLast Name
Phone number
Please enter a valid phone number.Format: (000) 000-0000.
Email address
example@example.com
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Emergency contact name

First NameMiddle NameLast Name
Visit Reason and Massage Preferences
Reason for Visit
Massage Goals
Previous Massage Experience
Pressure Preference
Areas to Avoid

Other
Current Pain and Symptoms
Location of Pain or Discomfort
Severity

1

2

3

4

5

6

7

8

9

10

1 is Mild, 10 is Severe
Duration
What Makes It Better
What Makes It Worse
Health History and Medical Screening
Heart or circulation problems?
If yes, please describe heart or circulation problems
High or low blood pressure?
If yes, please describe blood pressure concerns
Diabetes?
If yes, please describe diabetes details
Cancer or history of cancer?
If yes, please describe cancer history
Osteoporosis or low bone density?
If yes, please describe osteoporosis or bone density concerns
Blood clots or deep vein thrombosis (DVT)?
If yes, please describe blood clot or DVT history
Recent surgery or injury?
If yes, please describe the surgery or injury and date
Infectious or contagious illness?
If yes, please describe the illness
Skin conditions or sensitivities?
If yes, please describe skin conditions or sensitivities
Neurological conditions?
If yes, please describe neurological conditions
Any other medical conditions?
If yes, please describe other medical conditions
Current medications and supplements
Allergies and sensitivities
Are you currently pregnant?
If pregnant, which trimester are you in?
Anything else the therapist should know, including contraindications
Would you like to provide your physician or provider's contact information?
Physician or provider name

First NameMiddle NameLast Name
Physician or provider phone number
Please enter a valid phone number.Format: (000) 000-0000.
Consent, Acknowledgment, and Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Electronic Signature
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Should be Empty:

Client Intake & Consent Form

Client Information

Visit Reason and Massage Preferences

Current Pain and Symptoms

Health History and Medical Screening

Consent, Acknowledgment, and Signature